Every finding on record at Pine Crest Health and Memory Care

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. This had the potential to affect all 93 residents (R.) -The facility's measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems are not being performed based on nationally accepted standards and in accordance with their Water Management Program and the facility does not demonstrate they have system in place to monitor the control measures as indicated. -The facility did not disinfect equipment used during wound cares for R3. Registered Nurse (RN) L did not prevent possible cross contamination between wounds for R3. This could result in delayed healing of R3's wounds leading to a decline in R3's wounds. -RN C did not perform hand hygiene during dressing change for R4's coccyx wound. This could result in delayed healing and infection leading to a decline in R4's wound. Findings include: The facility's policy titled, Water Management Program, dated 3/6/2023 states, Potable Water System Monitoring Frequency. Temperature Monitoring - Take temps at specific points - Daily. Legionella Testing – Test 3 locations – Quarterly. Example 1 Water flushing logs indicated housekeeping was providing water flushes to vacant rooms twice a week. The facility did not have documentation of temperature monitoring or Legionella testing. The facility documentation did not control measures to prevent bacteria in the facility's water system were being monitored as indicated in their Water Management Policy. On 6/3/26 at about 8:30 AM, Surveyor interviewed Maintenance Lead O, who stated they just started in the position and don't know anything about what was required for water monitoring or testing. On 6/3/26 at 8:40 AM, Surveyor interviewed Registered Nurse (RN) D, who stated they were not able to locate any of the previous testing for bacteria or temperatures. RN D believes it was being done prior to previous Maintenance Lead's resignation in March but not able to locate those records. On 6/02/26 at 1:42 PM, Surveyor interviewed NHA A, who reported the facility has a water management program developed but the department in charge of implementing, operating and documenting what is to be done, was not made clear and was not done in accordance with their Water Management Program. Example 2 R3 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus with diabetic neuropathy and displaced bimalleolar (ankles) fractures of both right and left lower legs. R3 has a Brief Interview of Mental Status (BIMS) score of 15/15, which indicates intact cognition. R3 has physician orders dated 05/22/2026 which include: Right medial ankle, left medial, and lateral ankle: Apply Aquacel ag, apply bordered foam dressing. On 06/03/2026 at 11:57 AM, Surveyor observed RN L perform wound care to R3's right and left lower legs. Surveyor observed R3 had both medial (inside) and lateral (outside) surgical incisions to left ankle. During setting up wound care supplies, RN L removed a pair of bandage scissors from her uniform jacket pocket and laid them on R3's bedside table next to wound care supplies. Without first disinfecting the bandage scissors, RN L proceeded to cut to size clean dressings with the scissors. RN L opened a package of sterile saline wipe and cleansed the medial open incisional wound of left ankle. Using the same saline wipe, RN L then cleansed the lateral open incisional wound of left ankle. RN L placed the dressings cut using the undisinfected scissors onto both open wound care sites on left ankle. RN L place dressing cut with undisinfected scissors unto right ankle incisional wound. RN L removed gloves after wound care and assessed R3's left foot. RN L noted a new scabbed area below R3's anterior great toe. With bare finger, RN L palpated the left great toe wound, including scabbed area. On 06/03/2026 at 11:57 AM, during R3's wound care, RN L stated to Surveyor that due to lack of hand based alcohol rubs and wound care supplies in R3's room, RN L was aware of personal faults in being infection control compliant. Example 3 Resident (R) 4 was admitted to the facility on [DATE] with diagnoses of need for assistance with personal care and pressure ulcer of right buttock stage II. R4 had doctor's orders including a coccyx foam dressing change every other day and as needed, as well as applying Tegaderm to heels bilaterally every 3 days and as needed. On 06/02/2026 at 9:38 AM, Surveyor observed Registered Nurse (RN) C perform cares with R4. RN C assisted R4 with removing their wet shirt and put a dry gown on. RN C then removed R4's socks and the bandages on their heels. RN C then cleaned each heel with a betadine wipe. RN C removed the soiled gloves and put on clean gloves. RN C did not perform hand hygiene between glove changes. RN C put new foam dressings on R4's heels and signed and dated the dressings. RN C then untaped R4's briefs and pulled the front down and tucked it between R4's legs. RN C then wiped R4's front peri area. RN C rolled R4 onto their right side and pulled out the briefs which were soiled with BM and wiped R4's buttocks clean. RN C removed gloves and put on clean gloves without performing any hand hygiene. RN C removed R4's coccyx dressing and this area was wiped clean and soiled gloves removed, no hand hygiene performed. RN C put on clean gloves, placed a new dressing to R4's coccyx area, and began to put a clean brief on them. On 06/02/2026 at 10:02 AM, Surveyor informed RN C of the observations made of glove changes without performing hand hygiene. RN C informed Surveyor they normally have a small hand sanitizer with them and normally do perform hand hygiene with glove changes. But RN C did not have the sanitizer today. On 06/03/2026 at 3:44 PM, Surveyor informed Director of Nursing (DON) B of the observation made of glove changes without performing hand hygiene with cares provided to R4. DON B informed Surveyor RN C should have performed hand hygiene when removing gloves and when putting on clean gloves. On 06/04/2026 at 7:14 AM, Surveyor informed RN D (who is also the facility's infection preventionist) of the observation of cares with R4 and no hand hygiene performed with glove changes. RN D informed Surveyor that RN D will frequently quiz staff walking down the halls in the facility. RN D also indicated the facility's corporation took all of the hand sanitizer stations out of residents' rooms and it has changed the staff process, but it is not right.

Based on interview and record review, the facility did not have policies in place to provide residents a written notice of transfer to include reason for transfer, Ombudsman contact information, and appeal rights. This has the potential to affect all 93 residents.This is evidenced by:On 06/03/26, Surveyor requested the facility's transfer notice policy. Surveyor reviewed the facility's policy and noted no protocol to provide residents a written transfer notice that states the reason for the transfer, Ombudsman contact information, and appeal rights.On 06/03/26 at 2:51 PM, Surveyor interviewed Director of Nursing (DON) B regarding written transfer notices. DON B stated being unaware that there was a requirement to provide a written notice of transfer to residents unless they were being discharged .

Based on interview and record review, the facility did not provide residents a written notice of transfer that includes reason for transfer, Ombudsman contact information, and appeal rights to 10 of 10 residents (R7, R17, R8, R14, R99, R6, R83, R3, R96, and R101) reviewed.R7 was transferred to the hospital on [DATE]. A written notice of transfer was not completed.R17 was transferred to the hospital on [DATE]. A written notice of transfer was not completed.R8 was transferred to the hospital on [DATE]. A written notice of transfer was not completed.R14 was transferred to the hospital on 2/21/26. A written notice of transfer was not completed.R99 was transferred to the hospital on [DATE] and 04/15/26. A written notice of transfer was not completed.R6 was transferred to the hospital on 2/25/26. A written notice of transfer was not completed.R83 was transferred to the hospital on 3/16/26. A written notice of transfer was not completed.R3 was transferred to the hospital on [DATE]. A written notice of transfer was not completed.R96 was transferred to the hospital on 5/27/26. A written notice of transfer was not completed.R101 was transferred to the hospital on 4/21/26. A written notice of transfer was not completed.This is evidenced by: Example 1 On 03/26/26, R7 was transferred to the local hospital R7's medical record did not have documentation of a written notice of transfer. On 06/03/26 at 2:51 PM, Surveyor interviewed Director of Nursing (DON) B regarding written transfer notices. DON B stated being unaware that there was a requirement to provide a written notice of transfer to residents unless they were discharged . Example 2 R17 was admitted to the facility on [DATE]. On 04/30/2026, R17 was transferred to the hospital. R17's medical record showed documentation of a signed bed hold notice, dated 04/30/2026. No documentation of a written notice of transfer was found. Example 3 R8 was admitted to the facility on [DATE]. R8 was transferred to the hospital on [DATE]. R8's medical record showed documentation of a signed bed hold notice, dated 01/12/2026. No documentation of a written notice of transfer was found. Example 4 R3 was admitted to the facility on [DATE]. On 04/03/2026, R3 was transferred to the hospital R3's medical record showed documentation of a signed bed hold notice, dated 04/03/2026. No documentation of a written notice of transfer was found. On 06/02/2026 at 1:45 PM, Surveyor interviewed DON B and asked what the facility's policy was for providing residents/legal representatives with a written notice of transfer. DON B stated the facility did not provide written notice of transfers, and DON B was not aware this was a requirement prior to any transfers/discharges of residents. DON B was not able to provide evidence that a written notice of transfer was provided to R3, R8, and R17. Example 5 R14 was admitted to the facility on [DATE], with diagnoses including hyponatremia (low sodium levels,) hypocalcemia (low calcium levels,) hypomagnesium (low magnesium levels,) high blood pressure, and edema. R14's Minimum Data Set (MDS) assessment, dated 9/12/25, was titled Discharge Return Anticipated. Record review identified R14 was transferred to the hospital on 9/12/25, due to being found on the floor unresponsive. R14's electronic medical record did not have documentation of a written notice of transfer. Example 6 R6 was admitted to the facility on [DATE], with diagnoses including age related osteoporosis, anemia, osteoarthritis of right knee, history of stroke, abnormalities of gait and mobility, essential tremors, hemiplegia (partial paralysis) affecting right dominant side, and history of fracture of right arm humerus. R6's MDS dated [DATE] was titled Discharge. Record review identified R6 was transferred to the hospital on 2/25/26 due to potential fracture of arm after a fall. R6's electronic medical record did not have documentation of a written notice of transfer. Example 7 R83 was admitted to the facility on [DATE], with diagnoses that include history of stroke, congestive heart failure, adult failure to thrive, hypernatremia (high level of sodium,) hypokalemia (low potassium levels,) and type 2 diabetes. R83's MDS dated [DATE], was titled Discharge. Record review identified R83 was transferred to the hospital on 3/16/26 due to elevated sodium level and elevated blood sugar. On 6/2/26, Surveyor reviewed R83's electronic medical record. No documentation of a written notice of transfer was found. Example 8 R96 was admitted to the facility on [DATE], with diagnoses including pressure ulcer of sacral region stage 4, colostomy, paraplegia, osteomyelitis, and spina bifida. R96's MDS assessment dated [DATE] was titled Discharge Return Anticipated. Record review identified R96 was transferred to the hospital on 5/7/26 due to elevated sed rate (lab result) and concerns of osteomyelitis. R96's electronic medical record did not have documentation of a written notice of transfer. On 6/3/26 at 12:29 PM, Surveyor interviewed Medical Records (MR) P regarding the transfer process and paperwork as she handed off a copy of the bed hold to Surveyor. MR P stated honestly, we didn't know we had to do a written transfer notice for the resident or next of kin. We know about transfer notices to the hospital but not for the family/resident. MR P stated DON B now has a process put into place already so we can start doing that. Example 9 R99 was admitted on [DATE] with a Brief Interview for Mental Status (BIMS) score of 04/15, which indicated R99 had severe cognitive impairment. Review of R99's Electronic Health Record (EHR) had an MDS assessment dated [DATE] and 04/15/26 and were both titled, Discharge Return Anticipated. Surveyor was unable to find a notice of transfer in R99's medical record. On 06/03/2026 at 12:49 PM, Surveyor asked DON B for notice of transfer form for both of these two hospitalizations. DON B informed Surveyor that process was not being done at the time. Example 10 R101 was admitted to the facility on [DATE] with diagnoses of congestive heart failure and dementia. On 4/21/26, R101 was admitted to the hospital. Facility's bed hold policy was signed on 4/22/26. The facility did provide evidence that the Ombudsman was notified of R101's discharge. The facility did not provide written notice of transfer to resident or resident's representative.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 93 of 93 residents.-Surveyor observed an opened bag of cauliflower and an open bag of chopped celery were not dated with an expiration date, an open date, or a use by date.-Surveyor observed several individual uncovered bowls of lettuce without a date identifying when they were prepared. -Surveyor observed several uncovered prepared desserts without a date identifying when they were prepared.Findings include:On 6/1/26 at approximately 9:00 AM, during initial tour of the kitchen with Dietary Supervisor (DS) N, Surveyor observed in the walk-in freezer an open package of chicken breasts out of the original box without a use by or expiration date. Surveyor observed an opened bag of cauliflower and an opened bag of chopped celery without dates on them. DS N verified the opened packages did not have dates on them.Surveyor observed in the snack cooler, several individual bowls of uncovered lettuce salads without a date identifying when they were prepared. Surveyor observed in the dessert cooler, several individual bowls of uncovered prepared desserts without a date identifying when they were prepared.On 6/1/26 at approximately 9:15 AM, Surveyor interviewed DS N and asked what the expectation is for labeling and dating food items. DS N indicated they would expect opened/prepared food to be labeled and dated and prepared foods to be covered to prevent contamination when being stored for later use.

Based on observation, interview, and record review, the facility did not ensure diabetic foot care and treatment was provided, in accordance with professional standards of practice for 6 residents (R3, R4, R22, R56, R80, R83) of 6 diabetic residents reviewed for diabetic foot care in a sample of 20 residents.The facility did not:-Have physician orders for daily diabetic foot checks on R3, R4, R22, R56, R80, R83.-Have documentation in medical records that diabetic foot assessments and/or cares for R3, R4, R22, R80, and R83-Perform diabetic nail cares, specifically trimming toenails for R3. The facility's failure to provide diabetic foot care to residents could result in physical, mental and psychological harm to residents, including infection and poor hygiene. Findings include:The facility policy, titled Skin Integrity Foot Care, dated 08/07/2025, states, Facility to ensure residents receive proper treatment and care within professional standards of practice.to maintain mobility and good foot health.R3, R4, R22, R56, R80 and R83 were all admitted to the facility with diagnosis of Type 2 diabetes mellitus and diabetic peripheral neuropathy. Surveyor did not find physician orders for daily diabetic foot assessments/cares for R3, R4, R22, R56, R80 and R83. Surveyor did not find documentation of daily diabetic foot assessments during cares under certified nursing assistant (CNA) tasks for R3, R4, R22, R80 and R83. These residents had no nursing progress note documentation on assessments/cares during daily diabetic foot checks, including trimming of nails. On 06/03/2026 at 11:57 AM, Surveyor observed licensed Practical Nurse (LPN) L perform wound cares to R3's right and left lower legs. R3's toenails on both feet were not trimmed and stretched over top of nail bed extending underneath the toes. On 06/03/2026 at 11:57 AM, during wound cares, Surveyor asked R3 if nail cares were offered while at facility. R3 stated no one has ever trimmed his toenails and was not aware of toenails extending underneath toes because of diabetic neuropathy and lack of sensation to feet. On 06/03/2026 at 11:57 AM, Surveyor asked LPN L when diabetic foot cares were provided to R3. LPN L stated they had not noticed R3's toenails during wound cares prior. LPN L confirmed wound cares were provided to both of R3's feet, with toenails exposed, at a minimum of every 2 days, sometimes daily. LPN L stated nurses performed the wound cares and had visual access to R3's feet, including toenails. On 06/0302026 at 1:06 PM, Surveyor asked Director of Nursing (DON) B who performs diabetic foot cares for residents. DON B stated all nurses are expected to perform foot care, including nail trimming to diabetic residents. DON B stated CNAs inform nurses if new findings are noted during cares on diabetic residents. On 06/04/2026 at 7:25 AM, Surveyor asked Registered Nurse (RN) F, which staff perform diabetic foot cares for residents at the facility. RN F stated, I guess the nurses do? RN F informed Surveyor the facility had a podiatry nurse in the past, however no longer did. RN F could not recall if a particular staff nurse was currently designated to do diabetic foot assessments/cares at the facility.

Based on interview and record review, the facility did not ensure falls were investigated thoroughly to determine root cause, implement new safety interventions, and ensure adequate supervision for 1 of 8 residents (R) reviewed (R72).On 11/22/25, R72 had an unwitnessed fall. Root cause determined to be care planned intervention not in place. Facility did not complete thorough investigation to determine cause of safety intervention not in place, complete staff interviews, or evaluate staff competency.On 12/23/25, R72 had an unwitnessed fall with a resulting injury. Root cause determined to be care planned intervention not in place. Facility's investigation did not determine cause of safety intervention not in place, complete interviews with staff, or evaluate staff competency.On 03/28/26, R72 had an unwitnessed fall using equipment assessed to be unsafe without supervision. Facility's investigation did not determine if adequate supervision was in place, complete interviews with staff, or evaluate staff competency.On 04/25/26, R72 had an unwitnessed fall using equipment assessed to be unsafe without supervision. Facility's investigation did not determine if adequate supervision was in place, complete interviews with staff, or evaluate staff competency.This is evidenced by:Facility's policy titled, Fall Management System, with an effective date of 08/01/25, states: Policy: This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision.to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications.R72 was admitted to the facility on [DATE] with unspecified dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and memory deficit following cerebral infarction.R72's most recent quarterly Minimum Data Set (MDS), dated [DATE], noted a Brief Interview for Mental Status (BIMS) score of 10/15, indicating moderate cognitive impairment. R72 was noted to have one fall without injury and two falls with injury (except major).Surveyor reviewed R72's medical record and noted on 02/13/23, R72's durable power of attorney for healthcare due to incapacitation was initiated.On 06/03/25, R72 was assessed for ability to safely use electric recliner. The assessment noted R72 was not able to operate the controls appropriately.R72's care plan, with an initiated date of 08/01/25, and a target date of 06/09/26, states: [R72] has potential for falls related to CVA with left hemiparesis, dementia, weakness, balance deficit, seizure disorder, medications received, recent history of falls, decreased safety awareness and will be free of injury through review date. Interventions include: Dependent with use of electric recliner. -unable to use safely independently (Date Initiated: 08/01/2025). Pool noodle to right side of bed-left side of bed against wall (Date Initiated: 04/20/2026).Surveyor reviewed R72's fall notes and investigations:On 11/04/25, R72 had an unwitnessed fall in room. Facility investigation determined root cause to be R72 positioning self too close to the edge of the bed. New safety intervention to use a pool noodle to help R72 navigate boundary of mattress. R72's care plan was updated.On 11/22/25, R72 had an unwitnessed fall in room. R72 was unable to state what happened. Facility investigation determined root cause to be that staff did not place pool noodle on the bed. Re-education was completed with staff on ensuring pool noodle was placed on the bed and to follow R72's plan of care. No additional safety interventions were implemented. No staff interviews were completed. No staff competency evaluations were completed.On 12/23/25, R72 had an unwitnessed fall resulting in an abrasion on R72's left eyebrow. R72 was unable to state what happened. Facility investigation determined that the pool noodle was not in place. Re-education was completed with staff on ensuring pool noodle was placed on the bed and to follow R72's plan of care. No additional safety interventions were implemented. No additional skin assessments were documented of R72's injury. No staff interviews were completed. No staff competency evaluations were completed.On 03/28/26, R72 had an unwitnessed fall in room, falling out of electric recliner. Facility investigation determined root cause to be R72 resting in recliner unsupervised. New safety intervention to move R72's recliner to day area for R72 to rest with supervision and encourage rest periods in bed. No documentation of reviewing adequate supervision was noted. No staff interviews were completed. No staff competency evaluations were completed.Of note: supervised use of electric recliner was initiated on 08/01/25.On 04/25/26, R72 had an unwitnessed fall. R72 was found lying on floor next to recliner. Facility's investigation determined root cause to be sleeping in recliner. New safety intervention to attempt to place in bed on first rounds if in recliner. No documentation of reviewing adequate supervision was noted. No staff interviews were completed. No staff competency evaluations were completed.On 06/03/26 at 2:30 PM, Surveyor interviewed Assistant Director of Nursing (ADON) I regarding R72's falls. Surveyor asked ADON I how the facility determines the root cause after a fall if a resident is unable to state what happened and it is not witnessed. ADON I stated interviews with staff would be completed, audit of care plan, and additional review of staff involved. Surveyor asked ADON I if a review of staff competency was completed after R72's fall. ADON I stated no. Surveyor asked ADON I if audits or reviews were completed to determined adequate supervision of R72 using electric recliner. ADON I stated no. ADON I stated a more thorough investigation of R72's falls should have been completed.

Based on observation, interview and record review, the facility did not ensure residents received care and services for administration of parenteral medications consistent with professional standards of nursing practice for 2 residents (R17, R96) of 2 residents receiving parenteral medications reviewed in a sample of 20 residents. ~ R17 did not have arm circumference measurements at insertion site documented to ensure the peripherally inserted central line (PICC) was patent and not infiltrating into surrounding tissue during intravenous medication administrations. ~RN did not measure the circumference of R96's arm to ensure IV fluids via PICC line were not infiltrating surrounding tissue and not into the blood stream. Example 1 R17 was admitted to the facility on [DATE] and has diagnoses including Charcot-Marie-Tooth Disease (an inherited genetic condition that damages the peripheral nerves), right foot osteomyelitis (infection within the bone) and right hip septic arthritis. R17 has a Brief Interview for Mental Status (BIMS) score of 15/15, which means cognitively intact. R17 has a legal representative for healthcare decision making but is cognitively aware of medical diagnoses and treatment. R17's care plan, dated 05/08/2026, with target date 08/19/2026, states, Resident with right hip septic arthritis and right foot osteomyelitis. Interventions. administer antibiotic as per MD (medical doctor) orders. R17 has physician orders, dated 05/22/2026: Daptomycin 600mg (milligrams) intravenously (IV) one time a day for osteomyelitis. R17 has physician orders, dated 05/09/2026: Measure circumference of upper arm above insertions site daily. On 06/01/2026 at 10:00 AM, Surveyor observed R17 had a PICC line in place right upper arm. R17's PICC had a dated transparent dressing in place. R17 stated was aware of PICC placement and IV medication administration through the PICC. On 06/02/2026 at 11:23 AM, Surveyor asked R17 if nurses measured arm circumference at PICC site daily. R17 stated pretty much every day. R17's treatment administration record (TAR) for May 2026, did not have numerical documentation of daily arm circumferences. Beginning of 05/09/2026, R17's TAR has check marks at AM SH time with nursing initials for documentation of measurement of R17's arm circumference. R17's medical chart does not have nursing documentation of arm circumference measurements for comparison monitoring. On 06/02/2026 at 2:45 PM, Surveyor asked the nurse who measured R17's arm circumference earlier that day, licensed practical nurse (LPN) H, what R17's arm circumference was and where it was documented. LPN H stated there was no place to document a numerical value on the TAR. Surveyor asked LPN H how it was determined there was no change in R17's arm circumference if there were no numerical values documented daily for comparison. LPN H stated there was no way to determine changes in R17's arm circumference. Surveyor asked LPN H what R17's measurements were for the day, and LPN H stated, 3cm (centimeters). Surveyor asked LPN H if the measurement was accurate, and LPN H went to a medication cart, pulled out the paper measuring tape used for R17 and stated, I am wrong, it was 30cm, not 3cm. I don't know IV's well. LPN H stated if there were documented measurements for comparison, it would be easier to determine inaccurate measurements and possible infiltrations. On 06/03/2026 at 8:54 AM, Surveyor asked Director of Nursing (DON) B where nurses document arm circumference measurements on residents with PICCs. DON B stated on a resident's TAR. Surveyor asked DON B how nurses assess complications of a possible PICC infiltration without numerical measurements to know previous day's circumference on the TAR. DON B stated the facility's electronic medical record for the arm circumference documentation was not set up to enter numerical values; however, nursing can place a narrative note within the TAR. DON B confirmed there was no narrative charting and/or numerical values in R17's TAR of arm circumferences. Example 2 R96 was admitted to the facility on [DATE], with diagnoses including a stage 4 pressure ulcer of sacral region, colostomy, paraplegia, osteomyelitis, and spina bifida. R96's Care Plan, updated 5/28/26, states: Focus: Temporary: IV ATB (antibiotic) therapy with PICC (peripherally inserted central catheter) in place. Date initiated 5/28/26 Goal: Will not have any complications related to IV (intravenous) therapy through the review date. Interventions/Tasks: Monitor/document report to MD PRN (as needed) s/sx (signs and symptoms) of infiltration at the site: [E][NAME] at the insertion site, [T]aut or stretched skin, [B]lanching or coolness of the skin, [S]lowing or stopping of infusion, [L]eaking of I.V. fluid out of the insertion site. R96's physician orders include: Measure circumference of upper arm above insertion site daily. One time a day for PICC STANDING ORDER Measure circumference of upper arm above insertion site daily. 5/27/26 06:00. Surveyor reviewed R96's orders, MAR (medication treatment record) and TAR (treatment administration record). The order to measure circumference of arm was blank on the TAR since order started 5/27/26. On 6/2/26 at 8:28 AM, Surveyor observed Assistant Director of Nursing (ADON) Q hang R96's IV bag. ADON Q constituted (mixed) the IV, primed the tubing, set up the IV pump, and attached the IV to the PICC line using appropriate standards of care and infection control practices. ADON Q did not measure the circumference of R96's arm as ordered. On 6/4/26 at 7:38 AM, Surveyor interviewed ADON Q who stated they do not measure the circumference or change the dressing. ADON Q stated ADON Q schedules it to be completed usually on PMs, and the LPNs can do it. On 6/4/26 at 7:42 AM, Surveyor interviewed Licensed Practical Nurse (LPN) L who stated LPNs do not do anything with PICC lines. Surveyor clarified that Surveyor was referring to changing the dressing of the PICC line and not administering medication. LPN L stated no I wouldn't do that as I'm not trained on that. I can't, I am an LPN. On 06/4/26 at 7:44 AM, Surveyor interviewed ADON Q about when are LPNs trained on PICC line dressing changes and site assessment. ADON Q stated we do not do many IVs here. LPNS are not really trained, yeah some say they do it some say they don't. ADON Q stated ADON Q needs to talk with DON B about that. Surveyor asked for clarification what ADON Q stated in earlier interview about the order to be completed on the PM shift and the LPNs change the dressing and measure the arm circumference. ADON Q stated it was put on PMs because there is an RN also and they can help if the LPN does not do that. Surveyor asked if ADON Q could confirm that measuring order was scheduled for R96 on the PMs. ADON Q said no it is not but usually it is. 0n 6/4/26 at 8:08 AM, Surveyor interviewed DON B regarding the order to measure the upper arm circumference above the PICC line. DON B stated DON B believes R96 was one of the orders the template was updated for supplemental documentation in the TAR (treatment administration record.) DON B stated they can now document the measurements. DON B stated they will look for documentation of circumference sizes in progress notes and let Surveyor know. DON B stated the expectation is to follow the order. On 6/4/26 at 8:55 AM, DON B came back to Surveyor and stated we looked and looked and can't find any progress notes with measurements. DON B handed the June TAR to Surveyor and stated, this is the only measurement I can find. The MAR from June had a measurement from 6/3/26 only.

Based on observation, interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the residents' comprehensive plan of care for 2 of 20 residents (R7 and R1) reviewed.R7 has chronic lymphedema. R7's lymphedema was not being routinely assessed through measurements to monitor for worsening. R7 had a 2,000 ml daily fluid restriction that was not monitored daily.Facility did not document fluid intake every shift for R1 who is on fluid restrictions as ordered by physician which could result in fluid overload for R1.Facility did not perform and document daily weights and pulses as ordered by physician for R1 which could result in physical harm for R1.Facility did not notify physician for weights outside of parameters as ordered by physician for R1 which could result in physical harm for R1. This is evidenced by: Example 1 R7 was admitted to the facility on [DATE] with lymphedema and prothrombin deficiency (a blood clotting disorder). R7's most recent comprehensive Minimum Data Set (MDS) assessment, dated 04/10/26, noted a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition is intact. Surveyor reviewed R7's care plan and no interventions to monitor R7's lymphedema with measurements were noted. R7's orders: -Fluid restriction of 2,000 ml total daily. -Monitor fluid intake every shift. Surveyor reviewed R7's intake record and noted the following dates exceeding 2,000 ml restriction: -January 2026: 01/01, 01/02, 01/03, 01/04, 01/07, 01/12, and 01/29. No documentation was entered for PM shift noting fluid intake on 01/16 and 01/30. -February 2026: 02/11, 02/17, 02/18, and 02/28. No documentation was entered for PM shift noting fluid intake on 02/16 and 02/28. -March 2026: 03/01. 03/06, and 03/19. No documentation was entered on at least one shift noting fluid intake on 03/08, 03/11, 03/12, and 03/29. -April 2026: 04/01, 04/06, 04/07, 04/09, 04/21, 04/28, and 04/29. No documentation was entered on at least one shift noting fluid intake on 04/05, 04/11, 04/12, and 04/27. -May 2026: 05/05, 05/08, 05/10, 05/14, 05/16, 05/17, and 05/24. No documentation was entered on at least one shift noting fluid intake on 05/06 and 05/31. Of note: no documentation of additional assessments or notification of provider was noted on days when R7's intake exceeded 2,000 ml. Surveyor reviewed R7's weights between 01/01/26 – 03/25/26 and noted no significant increase in weight greater than 3 lbs. Surveyor reviewed R7's nursing assessments and noted R7 to have lymphedema swelling on R7's left upper extremity (LUE), left lower extremity (LLE), and right lower extremity (RLE). No nursing documentation of circumference measurements of these extremities were noted. Surveyor reviewed R7's Occupational Therapy (OT) notes. The following measurements were documented in total active girth (TAG): 12/23/25: RLE 245.4 cm. January 2026: no measurements documented. February 2026: no measurements documented. 03/18/26: RLE 251.1 cm 03/19/26: RLE 260.9 cm. 03/24/26: RLE 285.2 cm. -Of note: RLE increased 24 cm from 03/19/26 to 03/24/26. OT notes R7's right thigh area is hard to touch and larger than left leg. Nursing is monitoring for cellulitis, congestive heart failure, and blood clots. On 03/26/26, R7 was transferred to the hospital for evaluation for increased pain in right leg. Surveyor reviewed hospital notes, dated 03/26/26, and noted a CT was completed with findings of multiple hematomas in R7's right thigh. R7 was admitted to the hospital and discharged back to the facility on [DATE]. On 06/01/26 at 9:18 AM, Surveyor interviewed R7 regarding lymphedema assessments and treatment. R7 stated having chronic lymphedema that is treated by the facility's lymphatic therapist since admission. R7 stated that in March 2026, they noticed a sudden increase in pain in the right thigh but wasn't sure of the cause. Surveyor asked R7 if this was reported to nursing. R7 stated yes, but they did not report this right away. Surveyor asked R7 if nursing does assessments to measure the extremities affected by the lymphedema. R7 stated only therapy does this. Surveyor asked R7 how often measurements are completed by therapy. R7 stated not being sure but thinks it is typically monthly. On 06/03/26 at 8:06 AM, Surveyor interviewed Registered Nurse (RN) K regarding fluid restrictions and lymphedema assessments. Surveyor asked RN K how fluid restrictions are monitored. RN K stated nursing should review intake daily, total the amount and ensure any overages are documented in the resident's chart and reported to the provider. Surveyor asked RN K how nursing staff assesses lymphedema. RN K stated nursing assesses the skin for any changes. Surveyor asked RN K how nursing determines if the lymphedema is worsening or changing. RN K stated using weights. Surveyor asked RN K if nursing does any circumference measurements to monitor lymphedema as weight may not increase with worsening. RN K stated OT does the measurements. Surveyor asked RN K how often OT completes measurements. RN K stated they did not know. On 06/03/26 at 8:53 AM, Surveyor interviewed Director of Nursing (DON) B regarding fluid restriction monitoring. Surveyor asked DON B what the expectation is for nursing to monitor fluid restrictions. DON B stated nursing enters in the amounts and dietary typically reviews this. Surveyor asked DON B if there is any expectation for nursing to review daily to ensure intake does not exceed the physician order of a daily restriction. DON B stated no, not unless there is a concern or change in condition. Surveyor asked DON B how this current practice ensures a daily fluid restriction is monitored. DON B stated it doesn't and it would be most appropriate for nurses to tally and review the totals daily. On 06/03/26 at 2:03 PM, Surveyor interviewed DON B regarding R7's lymphedema assessments. Surveyor asked DON B how nursing staff assesses R7 lymphedema. DON B stated their charting system alerts nursing for specific concerns, like weight. Surveyor asked DON B how nursing staff know if R7's lymphedema is worsening. DON B stated nursing does daily skin assessments and will note if R7's wraps are tighter. Surveyor asked if this would be a reliable method to determine worsening of lymphedema. DON B was unable to answer. Surveyor asked DON B if nursing is expected to do any measurements of circumference to monitor lymphedema. DON B stated no, therapy completes this. Surveyor asked DON B how often therapy completes measurements. DON B stated they did not know. Surveyor reviewed OT's measurements with DON B between 03/18/26 – 03/25/26 and noted the 24 cm increase in R7's RLE. Surveyor also reviewed R7's weights during this timeframe with DON B noting no significant increase. Surveyor asked DON B if regular circumference measurements by nursing staff could have identified this significant change. DON B stated yes, measurements would be important in identifying worsening of lymphedema. On 06/04/26 at 7:51 AM, Surveyor interviewed Director of Therapy Services (DTS) M regarding R7's lymphedema assessments. Surveyor asked DTS M how often therapy assesses R7's lymphedema measurements. DTS M stated at least monthly. Surveyor asked DTS M if nursing also takes measurements. DTS M stated no. Surveyor reviewed R7's therapy notes with DTS M, specifically noting no measurements taken in January or February 2026 and the significant change 03/18/26 – 03/25/26. Surveyor asked DTS M if monthly assessments were appropriate given R7's complex medical history and how quickly the hematomas developed in R7's RLE affected with lymphedema. DTS M stated no, with all R7 has going on, this should be completed more often. Example 2 R1 was admitted to the facility on [DATE] with diagnoses including hypertensive heart disease, chronic kidney disease stage 4, and candidal endocarditis (rare and highly lethal fungal infection of the heart valves or inner lining) and chronic respiratory failure. R1 has a Brief Interview for Mental Status (BIMS) score of 15/15, which means cognitively intact. R1 makes own healthcare decisions. R1's care plan, dated 02/19/2026, which states, Has renal failure related to chronic kidney disease stage 4. Interventions include.monitor/document/report to MD (medical doctor) the following signs/symptoms.weight gain over 2 pounds a day.increased heart rate. R1's care plan, dated 02/11/2026, also states, At nutritional risk.Interventions include.Fluid restriction 2000 mls (milliliters). R1's medical record has physician orders, dated 02/25/2026, stating, Fluid restriction 2000 mls – dietary total 1,440mls – limit fluids with meals to 480mls, nursing total AM: 300mls, PM: 300ml. R1's medical record has physician orders, dated 02/18/2026, stating, Parameter/orders for resident with CHF (congestive heart failure): monitor for edema (swelling), fluid restriction of 2 liters, daily weights – update provider if 3-pound(lb.) weight gain/loss in 24 hours or 5-pound weight gain/loss in one week. One time a day. R1's medical record has physician orders, dated 02/11/2026 stating, Pulse parameters: if greater than 120 or less than 50.if remains abnormal.call MD. On 06/02/2026 at 7:08 AM, Surveyor observed a half full 20 oz (ounce) bottle of soda on R1's bedside table. The soda bottle did not have any dated markings on the bottle made by staff for monitoring fluid levels to measure R1's shift intake. R1 informed Surveyor their husband brings in sodas and snacks. R1 stated staff is aware family brings in extra fluids for R1. R1 confirmed awareness of being on fluid restrictions and stated they only drink limited amounts daily. R1 told Surveyor the bottle of soda was 3 days old. On 06/03/2026 at 8:03 AM, Surveyor observed a full 20 oz bottle of soda on R1's bedside table. The soda bottle did not have any dated markings on the bottle made by staff for monitoring fluid levels to measure R1's shift intake. R1 informed Surveyor their husband brought in the new bottle of soda last evening. Surveyor asked R1 if staff weighed them daily. R1 stated staff take weights only on the days they want to get out of bed. R1 stated some days the preference is to stay in bed, and no weight is done on those days, especially weekends. Surveyor asked R1 if staff checked their pulse daily and R1 stated, Yes. On 06/03/2026, record review of R1's task administration record (TAR) and/or medical chart for May 2026 found: -Daily weights are not documented for 14 out of 31 days, with a consecutive stretch of no weight documentation ranging up to a 6-day stretch. -Several nursing documentations of R1 remaining in bed for the day. There is no nursing documentation of weights not being obtained while R1 remained in bed. -No documentation of physician notification for: 05/08/2026 – one day 3 lb. weight gain; 05/25/2026 – 5 lb. weight loss (note: last weight done 05/22/2026); 05/28/2026 – one day 5-pound weight gain. -No nursing documentation of pulses on R1 for 15 out of 31 days. -No documentation of R1's fluid intake for one or two shifts for 6 out of 31 days. -CNA care plan indicates R1's fluid restriction status with dietary and nursing allowances noted. CNA care plan indicates daily weights for R1 are to be done. -R1's CNA and nursing care plans do not indicate family brings R1 bottles of soda with additional fluid measuring interventions for staff. -R1 does not have a risk/benefit education and/or consent for possible noncompliance of fluid restriction status. On 06/02/2026 at 11:08 AM, Surveyor asked CNA G and Licensed Practical Nurse (LPN) L where fluid intake for R1 is documented. CNA G stated in R1's chart. Surveyor asked LPN L how fluids are differentiated and totaled for monitoring purposes between dietary intake and medication allowance intake. LPN L stated nurses tell CNAs how much fluids were given to R1 during medication passes and CNAs add it to R1's totals when charting. LPN N stated it cannot be guaranteed this charting method of fluid intake for R1 is consistent amongst all nursing staff. On 06/02/2026 at 12:04 PM, Surveyor asked CNA J how staff document a resident's fluid intake when on fluid restrictions. CNA J stated fluid consumed during meals and any extra fluids are documented under CNA tasks in a resident's chart. CNA J stated they check with the nurses on what they give for fluids during medication passes and add it to the totals when documenting. On 06/02/2026 at 12:15 PM, Surveyor asked Registered Nurse (RN) F how a resident's fluid intake is documented. RN F stated they personally document fluids under the CNA tasks in a resident's chart. On 06/03/2026 at 10:44 AM, Surveyor asked CNA E how staff weigh R1 on days R1 prefers to stay in bed. CNA E stated staff can use the Hoyer lift (mechanical device for lifting that has a built-in scale) and raise R1 to a hovering position over the bed and obtain weight. CNA E stated weights are documented under the vitals task in R1's chart. On 06/03/2026 at 8:54 AM, Surveyor asked Director of Nursing (DON) B how residents who are on fluid restrictions are monitored and fluid intakes are documented. DON B stated the dietician monitors fluid intakes during monthly reviews. DON B stated nurses should document their medication pass fluids under CNA tasks but agreed this was not consistent within the facility. DON B could not confirm how nursing assesses a resident's fluid intake status accurately, and the medication administration record (MAR) should have a numerical option for documentation. DON B stated documentation under CNA tasks is the only current location to record fluids. Surveyor asked DON B if a resident desired to stay in bed and if weights were to be obtained daily, how staff should perform this task. DON B stated weights are not obtained and if a resident chooses not to be weighed, then it should be documented within the resident's medical chart. DON B confirmed a resident's care plan should indicate a resident's option to refuse getting out of bed, be weighed, and/or if a family brings in extra fluids that staff need to monitor intake status. DON B confirmed no care plan interventions or risk/benefit educations for R1 were in place.

Based on observation, interview and record review, the facility did not provide pharmaceutical services, including acquiring, receiving, and dispensing medications to meet the needs of 1 of 2 residents reviewed (R12).R12 had a physician order on 8/19/25 for Fidaxomicin for Clostridium Difficile (C-Diff). Pharmacy stated the medication was not available. Physician changed the order to Vancomycin HCL Capsule 125 mg by mouth every 6 hours until Fidaxomicin became available. Vancomycin was to be delivered on 8/20/25, and on 8/21/25, the pharmacy still had not delivered the Vancomycin. R12 was hospitalized on [DATE] to receive the Vancomycin for C-Diff management.The facility's Pharmacy Services manual read in part, Regular and reliable pharmaceutical service is available to provide residents with prescription and non-prescription medications, services, and related equipment and supplies. Provide routine and timely pharmacy services six days per week and emergency pharmacy services 24 hour per day, seven days per week.This is evidenced by:R12 was admitted to facility on 06/05/25 with a diagnosis of enterocolitis related to recurring clostridium difficile (C Diff) infection.R12's physician's orders included:Vancomycin HCl Capsule 125 MG. Give 1 capsule every 6 hours for C Diff until 08/22/25. Give until Fidaxomicin is available on or near 08/21/25.R12 tested positive for C Diff infection on 08/18/25. Order placed on 08/19/25 for Fidaxomicin. Pharmacy stated the medication was not available. Physician order changed to Vancomycin until Fidaxomicin became available. Vancomycin was to be delivered on 08/20/25. On 08/21/25, the medication had still not arrived.R12 was admitted to the hospital on [DATE] for C Diff Management.On 08/26/25 at 10:44 AM, Surveyor interviewed Registered Nurse (RN) G. RN G stated having difficulty getting medications in a timely manner from pharmacy at times. On this day an insulin pen was to be delivered and had not.On 08/27/25 at 12:25 PM, Surveyor interviewed RN I. RN I stated having difficulty receiving medications from the pharmacy in a timely manner. RN I stated recently there was an issue with the pharmacy stating they did not receive faxed orders, but the pharmacy is able to see them in the computer program also and is still not sending them on time. RN I stated calling the pharmacy to order the medication for R12. RN I stated the Fidaxomicin was not available, so Vancomycin was ordered. RN I stated the medication was to be delivered on 08/20/25 on the afternoon delivery.On 08/27/25 at 12:34 PM, Surveyor interviewed Licensed Practical Nurse (LPN) H. LPN H stated recently she has been having difficulty getting refill medications for residents. LPN H stated the pharmacy was having program issues and was unable to look anything up.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from abuse by another resident for 1 of 3 residents reviewed (R1). R2 was found in R1's room sitting next to R1's bed in wheelchair with his hand under the blanket on R1's bed. Facility did not protect R1 from further potential abuse when Surveyor's observations confirmed 15-minute checks on R2 were not performed, and R2 entered R1's room four more times after the incident. Findings include: The facility policy entitled Nursing Home Abuse, Neglect, Misappropriation, Exploitation, Resident to Resident Altercations, Injury of Unknown Origin, and Caregiver Misconduct (MVCC) last revised on 12/14/23, reads in part: Will take all necessary steps to ensure its residents are protected from incidents of abuse, neglect, and exploitation by anyone .The resident has the right to be free from abuse Individual treatment plans will also identify known history of distressed behavior including physical, sexual, or verbal aggression to ensure appropriate interventions. The facility's standard wandering protocol, last updated 03/28/24 reads in part: Monitor risk for wandering routinely and prn (as needed) .provide 1:1 as needed. R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with late onset, dementia, severe with psychotic disturbance, and anxiety disorder, unspecified. R1's most recent Minimum Data Set (MDS) assessment on 4/7/25 shows a Brief Interview for Mental Status (BIMS) score of 3/15, which indicates severe cognitive impairment and a Patient Health Questionnaire-9 (PHQ-9) score of 0, which indicates minimal symptoms of depression. R1's care plan prior to incident reads in part: Focus Risk for alteration in psychosocial, physical, emotional wellbeing or re-traumatization R/T diagnosis/history of natural disasters (tornado), resident's potential/or perception that she was jumped on a walk, potential sexual assault, severe human suffering due r/t her foster son evident by symptoms of anxiety, expressing feeling down. Implemented on 01/21/25 (Trauma Informed Care Assessment completed on 01/20/25) Goal I will be free from physical, social, and emotional harm and free from trauma and re-traumatization during my stay in facility. Intervention When I am having a hard time emotionally, the following strategy helps me feel better: Looking at my wedding photo or taking a drive. R2 was admitted to the facility on [DATE] with diagnosis including attention and concentration deficit following a stroke. R2's most recent MDS assessment on 05/22/23 shows a BIMS score of 3/15, which indicates severe cognitive impairment and a PHQ-9 score of 2, which indicates minimal symptoms of depression. R2's care plan prior to incident reads in part: Focus Resident at risk for elopement related to attempting to leave facility by himself. Resident resides in secure unit of facility Last revised 02/6/24 Goal Safety will be maintained, and resident will be accepting of redirection Interventions Adhere to standard of care wandering protocol Redirect with occurring wandering On 06/16/25, Surveyor reviewed R1 and R2's records and noted the following: On 11/18/24, Sexual Activity Consent completed for R2 confirmed R2 cannot consent. On 06/05/25, Sexual Activity Consent completed for R1 confirmed R1 cannot consent. On 06/05/25, the facility submitted a Facility Reported Incident (FRI) reported to the State Agency (SA), to report the incident of R2 touching R1. Facility interviews with staff during the facility investigation read in part: [R1] wanders into [R2's] room at night. She calls him another name (her husband's name). - Certified Nursing Assistant (CNA) H Once when I was walking with [R1] to her room we walked by [R2], and he made a comment to [R1] about her going into his bed. - CNA E Always trying to go into [R1's] room, nothing verbal. - Registered Nurse (RN) J Asks staff to get into bed with him. - Licensed Practical Nurse (LPN) G Facility interview with Hospitality Aide (HA) D states: On Thursday June 5th, I was in the common area/dining area in 300 wing and noticed that [R2] wasn't there .I noticed he wasn't in his room at all I heard someone yell out what are you doing, get out of here I realized it was [R1] so I went into her room [R1] was laying in bed and [R2] was in his wheelchair next to her bed. [R1] had her clothes on and blanket over top I said [R2] you're in the wrong room. [R2] started pulling his hand out from under her blanket. I did not see his hand but where his hand came out you could tell it was around the peri area .[R1] looked upset, and I pulled [R2] away and asked [R1] if she was ok. [R1] said she was but not to let it happen again [R1] came out of her room saying, where is he, where is he and at that time [CNA F] and [RN K] took [R1] to her room. [R2] laid down in bed for a nap There were a few more times early this week where [R2] was trying to go into [R1's] room. Facility interview with CNA F states: I proceeded to check on [R1], she was sleeping. About five minutes later she came out of her room upset and wanted to know where 'he' was. Then she started crying, talking about, 'he was touching' and she was confused. I tried calming her down, she was scared he was going to come back. She didn't like being alone, she was scared to be alone. Facility interview with RN K states in part: [R1] said she was scared and asked why he was touching her. I tried to explain but she kept crying and weeping [R1] asked if she could go back to sleep and make sure that guy didn't come in her room again We told [R1] we would watch [R2] closely and make sure he didn't come in again. The facility called law enforcement. Officer interviewed 3 staff members (Unit Manager (UM) C, HA D, and RN K) but no residents. No formal investigation was completed by law enforcement. The facility did not complete all staff education. R1's provider note from 06/16/25 reads in part, Wandering the halls at 3:30am trying to leave the facility .numerous questions for staff and anxiety behaviors discussed with husband and daughter increasing the Seroquel to 25mg at bedtime to see if this would improve her behaviors. Upon record review, R1's Seroquel 12.5mg started on 06/02/25 and was increased to 25mg on 6/17/25 which was already discussed as an intervention on 6/2/25 prior to incident. On 06/17/25 at 10:38 AM until 10:59 AM, Surveyors observed R2 for 21 minutes and no staff checked on R2. R2 is to be on 15-minute checks. On 06/17/25 at 10:38 AM, Surveyors entered the unit. Surveyors observed R1 in the dining room walking and talking with staff. R2 was observed lying in bed. On 06/17/25 at 10:50 AM, Surveyor attempted to interview R1. R1 was unable to stay focused to hold a conversation and was determined to be non-interviewable. On 06/17/25 at 10:59 AM, Surveyor interviewed CNA F. CNA F stated she was working the day of the incident but was performing cares on another resident. CNA F stated HA D informed her of what happened. CNA F stated after the incident, R2 kept going to R1's room. R1 reported to CNA F that R2 had touched her all over, but did not specify any particular body parts. R1 waved her hands all over to indicate it was everywhere. R1 was crying and stated she was worried about R2 coming back in her room. CNA F stated she laid R1 down and observed R1 for the rest of the day. CNA F also stated interventions were put in for keeping R2 at arm's distance from other residents, having him eat at the men's table, and to keep him in line of sight when out of his room. CNA F stated she never heard R2 say anything sexual to other residents. CNA F also reported she has not seen much change in R1's mood/behavior since the incident. R1 is usually happy during the day until after her husband leaves at dinner time. CNA F stated R1 had been weeping/crying for a few days after incident, but she has not observed anything since. CNA F also stated R1 had not slept in 3 days and said that was a change for her. On 06/17/25 at 11:07 AM, Surveyor interviewed CNA E. CNA E stated staff will redirect R1 if she is wandering and has not observed any changes in R1's behavior, appetite, or sleep. CNA E reported R2 had sexual behaviors towards staff but not residents. R2 tried one day before the incident to go into R1's room but was easily redirected. CNA E said they try to redirect R1 when she is in her moods. CNA E also stated R2 is on visual supervision while out of his room. CNA E confirmed she heard R2 state to R1, a comment to R1 about going into his bed. CNA E stated R2 made this comment, a while ago, reporting it was more than one month ago, but less than six months ago. On 06/17/25 at 11:17 AM, Surveyor interviewed RN K. RN K stated she had no knowledge of R2 making sexual comments/advances to residents, and that occasionally he would make comments to staff. When asked about 15-minute checks, RN K stated, The CNAs usually do that. RN K said the CNAs do the charting in the electronic medical record (EMR) system and they have no paper logs. RN K stated R2 is also on direct supervision when out of his room and he must be arm's length from other residents. RN K stated she has not observed a change in R1's behaviors since the incident, and the only intervention was to monitor R1 for behaviors like weeping/crying. On 06/17/25 at 12:27 PM, Surveyor interviewed Hospitality Aide (HA) D. HA D was present during the incident and was the staff who removed R2 from R1's room. HA D stated at the time of the incident she witnessed R1's eyes were big, and she looked scared. When HA D asked R1 if she was ok, she said she was fine, but don't let it happen again. HA D reported R1 brought the incident up that day but not since. HA D stated the interventions for R2 were 15 minutes checks, direct supervision when out of room, and arm's length from other residents. HA D reported after the incident R2 wandered into R1's room, but R1 was not present in the room when this happened. HA D stated staff were busy during the times R2 was able to enter R1's room. HA D reported no adverse events related to R2 entering R1's room. HA D stated the unit is always staffed with one licensed nurse, two CNAs, and one hospitality aide for approximately 16 residents on the unit. HA D stated staffing on the unit was sufficient to provide the increased supervision R2 required. HA D stated staff completed abuse education in May, as part of annual training. HA D confirmed after the incident occurred, she did not receive further abuse training. On 06/17/25 at 1:30 PM, Surveyor interviewed Unit Manager (UM) C. UM C stated she wouldn't say R1's behaviors have been different, just her anxiety has been more difficult to redirect. UM C stated R1 waxes and wanes with her behaviors. Some days she has them and some days she doesn't. UM C reported R1's antipsychotic medication was increased on 06/15/25; however, this was a change that was discussed when R1 was initially prescribed the medication on 06/02/25. The provider had indicated at that time, to start R1 on a half dose, and increase to full dose. The increase in R1's antipsychotic medication was not related to the incident or resulting impacts from the incident. On 06/17/25 at 2:49 PM, Surveyor interviewed R1's family member (FM) I. FM I stated, I don't think anything has necessarily changed, sometimes she talks about it. Last night [6/16/25], she was having kind of a manic night, she brought up a woman, who is from another incident, and a man who is [R2] from the incident which occurred on 06/05/25. She wasn't scared, I can't say that. She is going through med changes. Last night she wanted to go home and said something about being grabbed, by resident from other said incident, stating I don't want that to happen again, and that man [R2], that came in here, I don't want that to happen again. She was also talking about her childhood things during this conversation. I don't think there are any changes related to the incident or because of him. They are trying to dial in med changes, but I know it is still in her mind because she mentioned it. If it was ongoing I would want to do something about it, I feel the staff are doing what they can to prevent it from happening. I am excited about them (staff), they are super kind. On 06/17/25 at 3:14 PM, Surveyor interviewed Director of Nursing (DON) B regarding the incident between R1 and R2. DON B stated, We didn't really know for sure if this was sexual abuse, there was no evidence, but there was potential. He was not like that before with anyone else. When the CNA found him in [R1's] room, she moved him, his hand was not secured, he was not grabbing at anything, his hand moved with him when he was moved away from the bed. If he was doing something inappropriate, I think he would say or react when he was moved away, but he didn't react. We separated the residents immediately and began 15-minute checks on [R2]. SBAR was completed for [R2], as this behavior was a change in condition. Labs were done, and TSH was elevated, so [R2's] medications were adjusted. All other labs were normal. We implemented visual 1:1 when up and arm's length from others. This behavior was new for him. We wanted more eyes on him until we knew what was going on and for the protection of everyone. We completed abuse training in May. When we interviewed staff 1:1 we did informal education with them. DON B reported there was no documentation to confirm education had been completed. On 6/18/25 at 8:44 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A reported he feels the current interventions are working well. NHA A stated he would have to pull up the charting to know for sure. NHA A also feels staff are able to redirect R2 and intervene. NHA A also stated he believes R1 is protected when R2 has been able to get in her room since interventions were put in place. NHA A said staff were able to know R2 wasn't where he should be. NHA A also talked about the layout of the unit for better visibility. Care plan for R1 after incident reads in part: Focus Risk for alteration in mood or behavior R/T male resident being in room with hand under blanket. (intentions unknown) resident clothed (Implemented on 06/5/25) Goal Will have minimal to no episodes of fearfulness or emotional distress Interventions Staff will report any signs or symptoms or situations that may bring of emotional distress to resident monitor resident for any s/s emotional distress or fearfulness Monitor targeted behaviors and offer interventions and provider follow up as needed Staff will console and report any situations that may cause fearfulness or emotional distress and remove resident from the area/situation immediately will keep resident free from interactions with [R2] R2's care plan after the incident reads in part: Focus Risk for alteration in mood, behavior and mobility R/T being found in another resident's room with hand under blankets of clothed female resident (intentions unknown) (Implemented 06/05/24) Goals Will report any inappropriate sexual desires to staff/nurse will be free from any sexual inappropriate comments, gestures or advances towards other Will have decreased episodes of wandering Will have no episodes of evidence of inappropriate sexual/touching interactions with others R2's pertinent physician orders/behavior monitoring: No related medications Behavior-Is resident free from inappropriately entering other resident's personal space (such as entering other resident's rooms or placing himself within arm's reach of other residents) 6/11/25 Behavior-Is resident free from sexual behavior this shift? Implemented on 6/9/25 Facility implemented the following interventions on 06/05/25: 15-minute checks Visual line of sight when out of bed Avoid interactions with [R1] Assist to avoid entering other resident's room to respect personal space and boundaries (Implemented 06/11/25) Assist to remain arm's length away from others to respect personal space and boundaries (Implemented 06/11/25) Redirect when wandering (Implemented 06/12/25) Upon record review of progress notes, despite these interventions, R2 entered or attempted to enter R1's room on the following dates: On 06/06/25, R2 attempted to enter R1's room. On 06/07/25, R2 wandered into R1's room x2. On 06/08/25, R2 wandered into R1's room x1. Staff reported they didn't think R1 was in her room during these events but could not verify it.

Based on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional practice. This occurred for 1 of 3 medication storage rooms/carts observed, resulting in the potential to affect all 44 residents that reside on the north wing out of 73 residents that reside in the facility. This is evidenced by: On 4/30/25 at 6:49 AM, during inspection of north storage med room, Surveyor noted expired medications in the resident stock medications that included: Two bottles of Molnupiravir 200 mg (antiviral medication) one bottle unopened expired 8/23/24 and another bottle of Molnupiravir 200 mg unopened exp. 10/8/24. Surveyor interviewed Assistant Director of Nursing (ADON) G, who stated those should not be on the shelf. ADON G reported pharmacy is supposed to inspect stock medications and remove them. ADON G removed expired medication from the shelf and put in a bin to go back to pharmacy. Upon inspection of the medication fridge, Surveyor observed an opened multi-use vial of Aplisol -Tuberculin Purified Protein Derivative, Diluted (PPD) with no open date on box or the bottle. Surveyor interviewed ADON G, who reported the expectation would be that the vial and box would both be dated with the opened date and the vial only be used for 28 days. On 4/30/25 at 7:29 AM, Surveyor inspected the medication cart on north wing with Licensed Practical Nurse (LPN) V. Surveyor noted an open bottle of Clear Lax (liquid laxative) and Geri-Lanta (heartburn medication) not dated. LPN V reported these are for use of all residents on the north wing. LPN V stated she just opened the Clear Lax this morning and didn't have a sharpie to put the open date on it. LPN V could not identify when the Geri-Lanta was opened. LPN V put both opened medications back in the medication cart, opened and not dated. On 4/30/25 at 2:40 PM, Surveyor interviewed Director of Nursing (DON) B regarding medication storage, labeling of stock medication and opened multi-use vials. DON B stated she would expect multi-use vials to be dated when opened and to be disposed of within 28 days after opening and expired medications should not have been in stock medications. Record review indicated the bottle of multi-use vial of Aplisol-Tuberculin Purified Protein Derivative, Diluted (PPD) was opened on 2/14/25. This solution was expired as of 3/14/25 (28 days after opening). Nine doses were used on seven residents after medication had expired. On 5/01/25 at 8:41 AM, Surveyor interviewed DON B, who reported the medication room is the main medication room for stock supplies for the entire facility. However, the PPD solution kept in the north wing would only be for the north wing residents as the facility keeps another PPD solution in the south wing for residents.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 4 residents reviewed. (R43, R53, R27, R76) R43 is on contact precautions and staff did not wear the proper personal protective equipment (PPE) when providing cares. Hand hygiene was not performed for R53 as required for catheter cares, or during medication pass for R27 and R76. This is evidenced by: Example 1 R43 was admitted to the facility on [DATE]. R43's current diagnoses include, congestive heart failure, cellulitis of left lower limb, methicillin resistant staphylococcus aureus infection (MRSA), dementia, and muscle weakness. Minimum Data Set (MDS) admission assessment dated [DATE] documented R43's Brief Interview for Mental Status (BIMS) score of 5/15 indicating severe cognitive impairment. R43 requires maximum assistance from staff for lower body dressing, transfers, and showers. R43 is at risk for pressure injuries. During initial tour Surveyor observed a sign to the left of R43's door stating contact precautions and to wear gloves and gown. No personal protective equipment (PPE) bin was at entrance of the door. On 04/28/25 at 11:33 AM, Surveyor interviewed Certified Nursing Assistant (CNA) Q about the need for contact precautions for R43. CNA indicated R43 had a history of MRSA. On 04/30/25 at 7:10 AM, Surveyor observed CNA R enter R43's room asking R43 if she wanted to get up for breakfast. CNA R did not apply a gown while completing R43's personal cares. On 04/30/25 at 7:24 AM, Surveyor observed Licensed Practical Nurse (LPN) D enter R43's room. LPN D applied gloves and did not apply PPE of a gown. LPN D then applied the medication cream to both of R43's heels. LPN D removed gloves and sanitized hands. On 04/30/25 at 8:28 AM, Surveyor observed Licensed Practical Nurse (LPN) D speaking to CNA R. CNA R asked what PPE is to be worn. LPN D stated gowns only need to be worn when working with the infected area and when the area is draining and not contained. On 04/30/25 at 8:35 AM, Surveyor interviewed LPN D asking about contact precautions and enhanced barrier precautions (EBP). LPN D indicated contact precautions are when PPE is to be worn when working with the area that is contaminated. EBP is a step-up with a mask for when going into a room that is infected and would put all PPE on. When doing catheter care they would put PPE on. If the area is contained, then PPE would not be worn, only wear PPE when working on that area. On 04/30/25 at 8:55 AM, Surveyor interviewed Registered Nurse (RN) S about contact precautions PPE for R43. RN S indicated R43 is on contact precautions and staff are to wear gown and gloves for all contact. Staff are educated on the types of precautions and what PPE is to be worn. Surveyor reviewed the observation and interview. RN S indicated immediate education will be provided. 51095 Example 2 The facility policy titled: Hand Hygiene, reviewed on 8/8/24, states in part, .4.2. All staff shall use the hand-hygiene techniques, as set forth in the following procedure: .4.2.3. Before and after each patient/client/resident care procedure. 4.2.4. Before applying gloves; . 4.2.8 After contact with medical equipment/supplies in patient/client/resident areas, 4.2.9. Always after removing gloves . On 4/29/25 at 2:01 PM, Surveyor observed CNA T don a gown and gloves upon entering R53's room. R53 is on Enhanced Barrier Precautions (EBP) due to his Foley catheter. CNA T wheeled R53 into bathroom, assisted R53 in removal of outer clothes. and removed her gloves after helping him pull down his pants and sit back into wheelchair. CNA T did not use hand hygiene after removing her gloves and prior to donning new gloves to provide catheter cares. After CNA T emptied catheter leg bag and while CNA T was attempting to measure urine output, R53 stood up. CNA T stopped what she was doing to assist R53 to sit back in wheelchair. CNA T stated, In that instance I would have washed my hands before hand . CNA T went back to measuring urine, emptied urine in toilet, and then removed her gloves and did not use hand hygiene. CNA T applied new gloves, finished cares and doffed PPE, pushed R53's wheelchair out the door before using hand sanitizer when exiting the room. On 4/29/25 at 2:08 PM, Surveyor interviewed CNA T who was able to identify importance of EBP and infection control practices. CNA T was not aware she needed to use hand hygiene immediately after removing gloves prior to touching other surfaces. Example 3 On 4/29/25 at 3:45 PM, Surveyor observed LPN U look up medication in the electronic medical record, take medications out of the cart drawers, open packets and put meds in med cups, enter R27's room and hand R27 the medications. R27 took pills orally and handed the empty cup back to LPN U. LPN U left room and proceeded with setting up R76's medications without practicing any hand hygiene. After setting up medications, LPN U entered R76's room and handed medication cup to resident. After R76 swallowed the pills, LPN U took empty cup from resident and disposed of it in the trash. LPN U exited the room, went back to med cart and documented medications in the electronic medical record. At no time did LPN U practice any hand hygiene. Surveyor then interviewed LPN U about hand hygiene. LPN U stated, Oh man, I always forget. I didn't touch anything in their rooms though. Survey pointed out observation of LPN U touching the medication cups that the residents put to their mouths, the residents' doors, the computer mouse, the medication drawers and the medication wrappers. LPN U verbalized understanding of appropriate hand hygiene when passing medications and in between patients. On 4/30/25 at 2:41 PM, Surveyor interviewed DON B, who reported the expectation of the staff is to practice hand hygiene before and after entering residents' rooms, after performing cares, and immediately prior to and after donning/doffing gloves.

Based on observation, record review and interview, the facility did not report and respond to resident pain promptly to ensure prompt assessment and treatment of pain for 1 of 3 residents reviewed for pain. R25 expressed pain and need for medication during care. Certified Nursing Assistant (CNA) F did not stop care and summon a nurse for assessment and treatment of R25's pain. Nursing assessment of R25's pain was not initiated until 4 hours after R25's expressed pain. This is evidenced by: Surveyor requested and received the facility policy titled Pain Management dated 10/24/23. The policy in part read: Purpose: Nursing homes residents are at high risk for having pain that may affect function, impaired mobility, impaired mood, disturb sleep and diminish quality of life. Policy: It is the responsibility of (facility) to ensure that pain management is provided to residents who require such services . Recognition and Management of Pain: In order to help a resident attain or maintain their highest practicable level of well being and to prevent or manage pain .to the extent possible: ~Recognize when the resident is experiencing pain . ~Evaluates the existing pain and the cause . ~Manages or prevents pain . ~Pain is .evaluated when there is a change in condition and whenever new pain or an exacerbation of pain is suspected. Surveyor reviewed R25's record and noted R25's diagnosis included: ~Pain, unspecified. ~Dementia R25's record also showed R25 was enrolled in hospice 4/18/25. R25's most recent Minimum Data Set (MDS) dated [DATE] notes R25 usually understands and is usually understood. R25 is cognitively intact. R25 required substantial staff assistance for bed mobility, transfer and hygiene. R25 was frequently incontinent of bladder and occasionally incontinent of bowel. R25 had pneumonia and a urinary tract infection. R25 had no pain. R25 experienced falls with no injury or minor injury. R25 had no weight loss. R25 was at risk for pressure injury. R25 did not take opioid medication. Surveyor reviewed R25's care plan and noted the following: Focus: Alteration in comfort related to dementia. Goal: Residents PCL will remain at acceptable level for resident. Date Initiated: 5/14/24 Target Date: 4/29/25 Intervention/Task: Adhere to standard pain protocol. Surveyor requested and reviewed the facility's standard pain protocol and noted the following: Interventions as follows: RN/LPN (Registered Nurse/Licensed Practical Nurse): ~Monitor pain (PCL)q (every) 4 hours and prn (as needed) using numeric scale unless otherwise indicated in care plan. ~Monitor for impact of pain on daily function including but not limited to ADL's (activities of daily living) . CNA (Certified Nursing Assistant) ~Report to nurse if resident verbalizes or shows signs of symptoms of pain. R25's most recent comprehensive pain assessment dated [DATE] indicated no pain with rest or with movement. R25's physician orders included: NEW: Pain assessment to start on (4/29/25 PMs) and conclude on (5/5/25 PMs). Complete QD UDA x7 days in the evening for Pain assessment for 7 Days Complete pain assessment in UDA. Ensure correct dates/selection for initial, continuation and conclusion. When concluding, review previous 6 days of assessments. 4/29/2025 Icy Hot Original Pain Relief External Cream 10-30 % (Menthol-Methyl Salicylate (Liniments)) Apply to back & shoulder topically three times a day for pain 4/28/2025 No maximum daily dose on acetaminophen every shift for pain management. 4/28/2025 Acetaminophen Oral Capsule (Acetaminophen) Give 1000 mg by mouth three times a day for pain 4/28/2025 Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 5 mg by mouth every 2 hours as needed for pain Morphine Liquid 100mg/5mL, 5mg PO 4/21/2025 Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for pain 4/21/2025 Gaymar (Hot/Cold) Therapy as needed as needed for acute or chronic pain/comfort Max setting of 107 degrees F and min setting of 50 degrees F 5/15/2024 On 4/29/25 at 10:01 AM, Surveyor heard R25 yelling out in his room. At 10:04 AM, Surveyor observed CNA F assist R25 to sit up in bed and R25 stated, Easy, easy. CNA F asked R25, Are you hurting? R25 responded, Yes, my back, lower. CNA F proceed to use an easy stand to lift resident to stand from bed to take to the bathroom and lower R25 to toilet. R25 began yelling, Oh, oh. CNA F removed the sling from resident stand. R25 then requested a pill. CNA F expressed he will let the nurse know. R25 stated, Oh my back. R25 stated, I need a pill, which was repeated three times. R25 then stated, Don't need. A god damn pill. CNA F proceeded with washing R25's upper body and asked R25 about his pain. R25 stated, Pain in back. CNA F expressed he will let Medication Technician (MT) N know and proceeded with washing R25's back. R25 stated, Oh, feels good, with the washing of his back. CNA F then proceeded to wash R25's arms and R25 stated, No, Pain, I need a pill, I need a pill, louder. CNA F proceeded with dressing R25, and R25 stated, To hell with the god damn clothes. I need a pill. CNA F continued dressing R25, and R25 loudly stated, I need a pill. CNA F used the easy stand to lift R25 from the toilet, and R25 stated, Aww, Aww, when sling for lift was applied and stated, My pill, my pill. CNA F proceeded and lifted R25 with stand and performed peri care. R25 stated, Hurry up, Aww, aww, with washing and, Cut that out, Oh my back. Oh, my back, and CNA F continued. Surveyor asked CNA F if it is normal for R25 to yell. CNA F responded, No he is having more pain, in a lot of pain, more than usual for yelling, and proceeded to take R25 to recliner in his room with lift. CNA F lowered R25 to the recliner with R25 stating, Oh, oh, oh, oh, my back. CNA F told R25 he would tell MT N he needs something for pain pronto. CNA F removed the lift sling from R25, and R25 yelled, My pill, my pill, aww. Once transferred to recliner and sling was removed, R25's yelling stopped. After the observation, Surveyor interviewed CNA F about R25's pain and informing a nurse of R25's pain. CNA F responded nurses don't give meds in the bathroom, and he wanted to ensure in R25 was in his room and seated before letting a nurse know. Surveyor questioned if it is appropriate to continue with care when a resident is complaining of pain. CNA F expressed he was trying to hurry to meet needs and get situated to summon the nurse. Surveyor asked about resident complaint of pain. CNA F responded, Terrible, and was, Trying to make most comfortable. Surveyor asked CNA F if complaint of pain is new for R25. CNA F further expressed today was the first day taking care of R25 in a long time. CNA F indicated he had good intentions but perhaps he should have stopped care and gotten a nurse. CNA F retrieved MT N who entered R25's room with CNA F and asked R25 about his pain level. R25 responded, High. Surveyor noted the following additional observations: ~4/29/25 at 11:12 AM, R25 was seated in recliner in room and was no longer yelling. ~04/29/25 at 2:14 PM, R25 was visiting with visitor in room with no pain indicators. Surveyor reviewed R25's record and noted on 4/29/25, R25 was administered scheduled Acetaminophen 1000 MG at 12:00 PM at which time R25 rated his pain a 6; this is almost 2 hours after R25 expressed pain and a need for medication. R25 rated his pain a 0 at 4:00 PM and 8:00 PM on 4/29/25. Surveyor noted R25's pain comprehensive assessment by a nurse was not initiated until 2:12 PM on 4/29/25. On 4/30/25 at 10:56 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D and Nurse Manager/Registered Nurse (RN) E about R25's pain and the observation. LPN D indicated she would have expected CNA F to stop care and get a nurse when R25 was indicating he was in pain and needed a pill. LPN D further indicated nursing staff should complete a pain assessment having resident rate his pain, identify where the pain is located and get details about the pain. Nursing would check the resident Medication Administration Record and see what could be administered for a PRN (as needed) medication to address resident pain. LPN D expressed CNA F came to LPN D this morning and asked if a pre-medication was available prior to R25's care as CNA F was shaken by R25's pain with care yesterday. RN D expressed hospice was in to see R25 on Monday due to a fall R25 had over the weekend. Hospice increased R1's Tylenol and added icy hot to shoulders and back three times a day in addition to R25's as needed morphine as R25 had increased pain since his fall on the weekend. RN E further expressed she would expect R25's safety to be maintained first, then certified nursing assistants to summon a nurse to assess resident pain and treat as needed. Surveyor asked RN E if a pain assessment was completed by a nurse for R25 after his expression of pain during the observation. RN E expressed she would look for an assessment and let Surveyor know. RN E expressed a hospital bed has been provided instead of R25's standard bed to increase R25's comfort. On 4/30/25 at 2:37 PM, Surveyor interviewed Director of Nursing (DON) B about the observation and her expectations. DON B expressed she would expect staff to stop care and notify nurse. She would expect a nurse to complete a comprehensive pain assessment and administer medications as ordered. DON B indicated a comprehensive pain assessment was not started until PM shift and is not yet completed. DON B further indicated MT N should have notified a nurse right away when R25 reported high pain level so an assessment could be completed. DON B expressed R25 was administered his scheduled Tylenol at 12:00 PM but he has as needed morphine that was available.

Based on observation, interview, and record review, the facility failed to recognize and assess an inability to perform Activities of Daily Living (ADL)s and implement interventions in accordance with the residents' assessed needs for 2 of 2 residents reviewed (R55, R65). Findings include: Standard ADL Protocol dated 03/28/24 states in part, Monitor for changes in Resident's ADL participation routinely. It also states in part, Report to your nurse if resident has a decline in ADL status or has been requiring increased assist with cares. Standard Nutrition Protocol dated 03/28/24 states in part, Encourage adequate intake of foods and fluids. Example 1 R55 was admitted to the facility on [DATE]. Pertinent diagnoses include unspecified dementia, unspecified severity, with agitation, age related cognitive decline, and depression, unspecified. R55's Minimum Data Set (MDS) assessment, dated 02/04/25, reads in part, Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Assessment reflects a Brief Interview for Mental Status (BIMS) score of 01/15 indicating a severe cognitive deficit. Significant change assessment started on 04/29/25 noted decline in BIMS score to a 00. R55's care plan last reviewed on 02/19/25 includes in part: The resident has a potential for alteration in cognition/mood Resident to participate in activities as able. At nutrition risk for altered nutrition status related to advanced age, comorbidities, cognition with history of refusal of cares and medications that can impact weight/appetite. Provide supervision/oversight with meal/tray set up assist as needed. Dining - set up assist/supervision Adhere to standard ADL protocol Reapproach as needed with decline of care delivery Record review did not indicate any significant weight loss. On 04/28/25 at 12:15 PM, Surveyor observed R55 receiving her lunch. Surveyor observed R55 sitting approximately a foot from the table with no encouragement or assistance from staff to move closer. On 04/28/25 at 12:20 PM, Surveyor observed R55 leaning forward to reach her brownie and having a difficult time. On 04/28/25 at 12:32PM, Surveyor observed R55 eating food with her fingers from the table that dropped off her plate. On 04/28/25 at 12:44 PM, Surveyor observed Registered Nurse (RN) L ask R55 and tablemate how lunch was but did not offer assistance and walked away. On 04/28/25 at 12:50 PM, Surveyor observed RN L ask R55 if she was done and took her plate. Surveyor observed RN L offering to hand R55 her apple juice and then left the table. No assistance was offered to R55 the entire meal. Surveyor observed R55 had eaten less than 25% of her meal. On 04/29/25 at 11:45 AM, Surveyor observed R55 receive her lunch. Surveyor observed Licensed Practical Nurse (LPN) K set up plate for R55 and explain what she had in front of her to eat. Surveyor observed LPN K then go to deliver another resident's food. On 04/29/25 at 11:56 AM, Surveyor observed R55 sitting at the dining room table watching TV and attempting to eat her dessert. On 04/29/25 at 12:27 PM, Surveyor observed R55 had eaten approximately 25% of her meal before dishes were removed from the table. No further assistance was offered. On 04/30/25 at 11:52 AM, Surveyor observed R55 receive lunch and Certified Nursing Assistant (CNA) I set up her lunch in front of her. On 04/30/25 at 12:00 PM, Surveyor observed R55 sitting at table with her eyes closed and not eating. On 04/30/25 at 12:26 PM, Surveyor observed R55 awake and sitting at table with plate untouched. On 04/30/25 at 12:29 PM, Surveyor observed RN P walk by and ask R55 if the food was good but did not stop. Surveyor observed R55 begin to eat independently at this time. Surveyor observed R55 had eaten approximately 25% of her meal. On 04/30/25 at 3:30 PM, Surveyor interviewed CNA M. CNA M stated if they need to know if a resident requires ADL assistance, they can look in the Kardex. It will tell them if the resident requires setup for meals and what their diet is. CNA M also stated if a resident is independent and she notices the resident is not eating, she would explain to the resident what she is doing, offer assistance, encourage the resident to eat, and possibly offer other options. CNA M stated she would also ask the resident if there was a reason they were not eating. On 04/30/25 at 3:35 PM, Surveyor interviewed LPN J. LPN J stated if staff needed to know what assistance was required, they would look in the care plan or Kardex. The Kardex and/or care plan would list if a resident required cuing, encouraging, setup, assistance, or if they were independent. LPN J stated if she observed a resident that was independent that was not eating or unable to eat, she would offer assistance and if warranted, update therapy for possible evaluation. Example 2 R65 was admitted to the facility on [DATE]. Pertinent diagnoses includes unspecified dementia, moderate, with other behavioral disturbance. No Brief Interview for Mental Status (BIMS) score available. R65's care plan, last reviewed on 04/15/25, includes in part: Adhere to standard Activities of Daily Living (ADL) protocol Dining: set up assist, provide cuing. At nutrition risk for altered nutrition status related to advanced age, comorbidities and cognition w/ behaviors that can impact weight/appetite. Provide meal/tray set up assist, provide cuing as needed during meal intake On 04/28/25 at 12:13 PM, Surveyor observed R65 receive her meal. On 04/28/25 at 12:18 PM, Surveyor observed R65 sitting at the table with her meal in front of her but not making any attempt to eat. On 04/28/25 at 12:46 PM, Surveyor observed RN L look at R65, say nothing, and walk away. On 04/28/25 at 12:48 PM, Surveyor observed RN L say to R65 You didn't like that chicken huh? and then offered R65 water. On 04/28/25 at 12:51 PM, Surveyor observed RN L offer to cut up R65's brownie and again offered to get her some water but not to assist her with eating or eating her main entree. On 04/28/25 at 12:56 PM, Surveyor walked around the loop in the hallway and returned immediately to the dining room. R65's tray had been removed from the table. On 04/29/25 at 12:00 PM, Surveyor observed CNA I. CNA I attempted to assist R65 with lunch. R65 responded, Yes, when asked if she wanted a drink of juice or a bite of dessert but would not open mouth and receive either one. Surveyor observed CNA I then remove tray from room. On 04/30/25 at 12:00 PM, Surveyor observed R65's lunch tray delivered to her room. On 04/30/25 at 12:12 PM, Surveyor observed lunch tray sitting in R65's room. No staff present. Resident was sitting up with eyes closed. Surveyor observed RN P standing down the hallway near the dining room. On 04/30/25 at 12:13 PM, Surveyor observed RN P instruct Hospitality aide (HA) O to look to see if CNA H was assisting R65 with lunch. HA O told Surveyor CNA H would be to R65's room to assist her shortly. On 04/30/25 at 12:15 PM, Surveyor observed RN P talking to CNA H and advised her to go assist R65. On 04/30/25 at 12:17 PM, Surveyor observed CNA H apply PPE and enter room. On 04/30/25 at 12:19 PM, Surveyor observed CNA H attempt to clean R65's hand with a moist towelette. R65 was swinging her arms and batting the towelette away. CNA H attempted to assist her with a bite of food. Resident declined. Surveyor observed a couple more attempts made by CNA H to offer R65 a bite/drink before removing tray from room. On 04/30/25 at 3:45 PM, Surveyor interviewed Director of Nursing (DON) B, asking about assisting dependent residents with meals. DON B stated if staff needed to know if a resident required assistances with ADLs, specifically meals, they could look in the care plan or Kardex. DON B stated if a resident was served a meal and not eating, she would offer assistance, assess the situation, and offer oral care if needed.

Based on interviews and record reviews, the facility did not notify provider as indicated for development of a skin wound for 1 of 18 residents, (R) R43, reviewed. This is evidenced by: R43 was admitted to the facility on [DATE]. R43's current diagnoses include, congestive heart failure, cellulitis of left lower limb, methicillin resistant staphylococcus aureus infection, dementia, and muscle weakness. Minimum Data Set (MDS) admission assessment dated [DATE] documented R43's Brief Interview for Mental Status (BIMS) score of 5/15 indicating severe cognitive impairment. R43 requires maximum assistance from staff for lower body dressing, transfers, and showers. R43 is at risk for pressure injuries. Initial care plan was developed for potential for skin breakdown related to dementia, limitations in mobility, occasional bowel incontinence, cardiac diagnosis, and pain. On 03/25/25, a temporary care plan was developed for alteration in skin integrity related to self-inflicted scratching evidenced by a wound to left lower extremity. Interventions include: wound will resolve without complications, complete treatment as ordered by MD, monitor for signs of infection, update MD with any changes in wound status. Progress notes documented on 03/8/25 at 7:01 PM, Health Status Note, Note Text: Resident scratched her lower left leg; outer aspect above her left ankle. She had a skin tear measuring approx 2 cm x 2 cm. This writer approximated the skin tear with 4 steri strips. The physician was not notified of the new skin breakdown. On 03/20/25 at 6:46 PM, Health Status Note, Note Text: This writer was called to resident's room by CNA. Resident wants to scratch her scab on her left lower leg/out aspect. This writer applied a non-adherent 3 in x 4 inch pad and lightly secured with Coban. Educated resident on necessity of not scratching her skin as she is prone to skin breakdown. On 03/22/25 at 5:11 PM, Health Status Note, Note Text: Residents scab on her left lower leg (outer aspect) came off as it was attached to her sock. The scabbed area is now open again. This writer applied a 4x4 non-adherent pad and secured it with Coban. On 03/23/25 at 1:58 PM, COMMUNICATION - with Family/NOK/POA Note Text: [R43] has a 1.5cm x 1cm open area on her left, lower, lateral leg. It has a pink wound base and a black scab edge at the top perimeter of the area . The facility had not notified the physician of the skin breakdown and to obtain order for treatment. On 03/25/25, the progress notes documented an open oval area that had small amount purulent drainage and peri area red. The physician was updated at this time and orders were obtained for a culture of the wound. On 04/30/25 at 8:29 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D asking about the process of when an open area of a skin tear is identified and steri strips are applied. LPN D indicated fax the MD and ask for orders. If worsens would get wound nurse involved and take it from there. On 05/01/25 at 9:34 AM, Surveyor interviewed Director of Nursing (DON) B about notifying the physician of the open area when it occurred. DON B indicated the provider should have been notified of the open area.

Based on observation, interview and record review, the facility did not ensure the daily nurse staffing information was posted at the beginning of each shift. This has the potential to affect all 73 residents in the building. The facility did not update the daily nursing staff postings when there were schedule changes. Evidenced by: The facility policy titled: Sufficient Nursing Home Services: dated 09/01/2000, states: 4.1 Nurse Staffing information. NCHC must post the following information on a daily basis: -Facility name -The current date -The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. According to federal regulations, the facility must post the nurse staffing data on a daily basis at the beginning of each shift. Data must be posted as follows: -Clear and readable format. -In a prominent place readily accessible to residents and visitors. -Resident census. -The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. The information should reflect staff absences on that shift due to callouts and illness. On 04/28/25 at 8:46 AM, upon entrance, Surveyor observed the staff posting in lobby which was dated 04/25/25 and indicated the facility census was 74. On 04/28/25 at 9:04 AM, Surveyor asked Administrative Assistant (AA) C where to locate the updated staff posting. AA C pointed to where the staff posting was located and stated, It is probably still Friday's posting as I hadn't gotten to it yet today. On 04/28/25 at 12:15 PM, Surveyor reviewed staff schedules and staff postings for period of 04/15/25 through 04/29/25 which reflected no changes made when staff absences occur. On 04/28/25 at 1:15 PM, Surveyor interviewed AA C who told Surveyor the staff posting was updated with today's posting around 10:45 AM. AA C stated she receives an email from schedulers with staffing information and enters the information and current census on a form in the computer, prints and posts on wall. Surveyor asked Administrative Assistant C if the posting is updated as staffing levels change including on weekends. Administrative Assistant C stated that the form is not updated when staffing ratios change nor posted on weekends, stating, We try, but I am not here on weekends. On 04/30/25 at 11:14 AM, Surveyor interviewed Director of Nursing (DON) B regarding process of staff postings. DON B stated the schedulers will email AA C the information and AA C will fill out the posting template, print and post in lobby area. Surveyor shared findings upon initial entrance of survey on 04/28/25 of posting that was dated Friday 04/25/25 and indicated incorrect census. DON B believes that the weekend postings are printed and placed behind Friday's posting, but unable to provide information on how the postings are updated to ensure the correct date/census. Surveyor asked DON B regarding process of updating current staffing ratio if there was a call in, etc. DON B indicated there was not a process to ensure posting reflects updated staffing ratios.

Based on interview and record review, the facility did not ensure residents (R) receive food that accommodates the residents' preferences and options of similar nutritional value are provided for residents who choose not to eat the food that is initially served for 1 of 3 residents reviewed. (R6) Finding include: The facility policy titled, Diet Manual and Diet Order Terminology, states, .3.3 During meal observation, monitor tickets for accuracy of resident information and understanding of ticket information by nursing staff . The facility policy titled, Dining Services Guidelines, states, .Offer alternatives meet the nutritional, religious, cultural, and ethnic needs, and preferences of the resident . R6 was admitted to the facility on [DATE] with diagnoses that include, diabetes, severe obesity, heart failure and gastrointestinal reflux disease. R6's Minimum Data Set (MDS), dated [DATE], identified that R6 has a Brief Interview for Mental Status (BIMS) score of 15 that indicates that R6 has intact cognition. MDS also stated R6 has clear speech, understands, and is understood. R6 requires staff assistance for bathing, transfers, toileting, and set up assistance for meals. On 10/14/24 at 12:45 PM, Surveyor interviewed R6 and asked if R6 is receiving the correct meals regarding allergies, preferences, and restrictions. R6 replied, No. For instance, this morning it is clearly on my meal ticket that says not to give sausage or gravy and that it what I got. Surveyor asked R6 if it was reported to kitchen. R6 stated, I did have the aide tell the kitchen, then they gave me hard boiled eggs instead. It is just frustrating because I seem to have to do this all the time. Surveyor clarified that the resident noticed the error and not the dietary staff or the aide that passed the tray. Surveyor reviewed R6's dietary note, dated 07/10/24, which states, .Tray card updated w/preferences (does not like fish, no cow, no pork sausage) . On 10/14/24 at 1:15 PM, Surveyor interviewed Certified Nursing Assistant (CNA) C and asked how it is known which residents have dietary restrictions and what do you do if a resident receives food/fluids that are restricted or not wanted. CNA C stated that meal tickets come on the trays from the kitchen with the allergies, likes/dislikes, and special plates, cups etc. We check that against what they get. They do have to bring items back to the kitchen sometimes. It seems to go in waves where it is good for a while, then there are times that we are bringing things back a lot. For instance, sometimes we get liquids that are supposed to be a certain thickness and it is too runny. Sometimes they do give residents something they do not like. When that happens, we notify the kitchen staff, and they give something else. On 10/14/24 at 3:53 PM, Surveyor interviewed Director of Nursing (DON) B and shared the concern above. Surveyor asked about resident's meal ticket expectations regarding allergies, likes/dislikes, and equipment. DON B stated it would be expected that staff in the kitchen provide meals per the doctor orders and residents' preferences and not to receive food with allergies. It is expected that the staff passing the trays check the foods against the tickets to ensure residents are receiving the appropriate foods, consistencies, and adaptive equipment.

Based on interview and record review, the facility did not develop a resident-to-resident altercation comprehensive person-centered care plan for 3 of 3 sampled residents (R2, R1 and R3). Findings: The facility policy, Abuse, Neglect, Misappropriation, Exploitation, Resident to Resident Altercations, Injury of Unknown Origin, and Caregiver Misconduct, stated in part . North Central Health Care (NCHC) will take all necessary steps to ensure its Patients/clients/residents are protected from incidents of abuse, neglect and exploitation by anyone . II. Purpose: To provide guidance to staff in identifying and responding to incidents of abuse, neglect and exploitation and to ensure compliance with regulatory requirements . IV. General Procedure . C. Prevention and Monitoring . 4. Individual treatment plans will be adjusted when indicated to reduce the potential for conflict and/or neglect. 5. The interdisciplinary team will provide supervision of staff to ensure the identification of inappropriate conduct, appropriate assessment, care planning and monitoring of patient/client/ resident's needs or behaviors. Example 1 R2 was admitted to the facility on [DATE], diagnoses included dementia, weakness, anxiety, and pain. R2's Minimum Data Set (MDS) assessment completed on 07/24/24, revealed R2 scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicates severe cognitive impairment. R2 no longer uses a cane or any assistive devices to walk, and staff must anticipate R2's needs. On 06/10/24, the facility submitted a misconduct incident report. The report indicated the incident was investigated as a resident-to-resident altercation and potential situation for abuse involving R1 and R2. On 08/20/24, Surveyor reviewed R2's care plan with most recent update, dated 08/08/24. R2's care plan did not address the resident-to-resident altercation with R1 and the interventions to prevent the recurrence. Example 2 R1 was admitted to the facility on [DATE] and diagnoses included repeated falls, pain, dementia, and paraplegia. R1's MDS assessment completed on 07/24/24, revealed R1 scored a 1 on the BIMS assessment which indicates severe cognitive impairment. R1 uses a wheelchair and relies on staff assistance with all ADLs. Due to R1's cognition, staff must anticipate R1's needs. On 08/20/24, Surveyor reviewed R1's care plan with most recent update, dated 07/22/24. R1's care plan notes that R1 has episodes of verbal and physical behaviors. There is no mention that R1 had a resident-to-resident altercation and interventions in place to protect R1 from the negative behavior of R2. Example 3 R3 was admitted to the facility on [DATE] and diagnoses included Alzheimer's disease, contractures, pain, weakness, anxiety, and depression. R3's MDS assessment completed on 06/04/24, revealed R3 has no score on the BIMS assessment and indicates severe cognitive impairment. R3 is dependent on staff for all ADLs, is non-verbal and relies on staff for all mobility using a wheelchair. On 03/03/24, the facility submitted a misconduct incident report identifying R1 had made contact with R3's head with a rolled-up magazine. On 08/20/24, Surveyor reviewed R3's care plan dated 10/06/22. R3's care plan did not address the resident-to-resident altercation with R1 and the interventions to protect R3 from the negative behavior of R1. R1's care plan did not address the resident-to-resident altercation with R3 and the interventions to prevent the recurrence. On 08/20/24 at 11:50 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A to provide the care plans for R1, R2 and R3 regarding their resident-to-resident altercations. NHA A provided a synopsis of the incident and care plan for R2 that addresses possible causes of the increased aggression. Surveyor then asked NHA A where the plan clearly defines the incident and interventions to address and prevent the recurrence. NHA A stated it is probably in the medication administration record (MAR) under behavior tracking. Surveyor pulled up R2's MAR on the computer, and NHA A stated, I don't see it there, let me check on this and get back to you. On 08/20/24 at 11:53 AM, NHA A returned and stated, We should have done a better job at addressing the care plan and the behavior monitoring in the MAR.

Based on observations, interviews and record reviews, the facility did not ensure 2 of 4 residents (R1 and R24) reviewed were administered medications in a safe manner. This is evidenced by: Surveyor reviewed R1's medical record and noted the following: R1 was admitted on [DATE] with diagnoses of dementia with psychotic disturbance and dysphagia. R1 has an activated power of attorney (APOA) with incapacitation documentation dated 01/12/24. The admission minimum data set (MDS) dated [DATE] with a Brief Interview for Mental Status (BIMS) score of 15, indicated she is cognitively intact. On 03/04/24 at 10:06 AM, Surveyor observed R1 in private room ambulating self with walker to sit on her bed. Surveyor asked permission to enter room and interview R1. Surveyor observed a medication administration cup with 4 various pills on R1's bedside table. Surveyor asked R1 if those were R1's pills. R1 stated they were and that R1 would be taking them in a little bit. Surveyor asked where the pills came from and R1 responded that the nurse gave them to her. Surveyor asked if R1 knew what the medications were. R1 responded that R1 did not, but they are the pills R1 takes every morning. Medication teaching assessment completed 01/12/24 with the following two questions and answers: Is the resident short term? No. Do they want to self-administer medications? No. R1's medication orders: ~Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) ~Vitamin B Complex Oral Tablet (B-Complex Vitamins) ~Pravastatin Sodium Oral Tablet 40 MG (Pravastatin Sodium) ~Potassium Chloride ER Oral Capsule Extended Release 10 MEQ (Potassium Chloride) ~Apixaban Oral Tablet 2.5 MG (Apixaban) ~Vitamin D3 Oral Capsule 25 MCG (1000 UT) ~Bumetanide Oral Tablet 2 MG (Bumetanide) ~Polyethylene Glycol 3350 Powder ~Sennosides-Docusate Sodium Tablet 8.6-50 MG ~Bisacodyl Suppository 10 MG ~Docusate Sodium Capsule 100 MG ~Magnesium Hydroxide Suspension 400 MG/5 ML ~Acetaminophen Tablet Give 325 mg. Example 2 Surveyor reviewed R24's medical record and noted the following: R24 was admitted on [DATE] with medical diagnoses of hypertension, atrial fibrillation, congestive heart failure, interstitial lung disease, arthritis. R24's most recent quarterly MDS dated [DATE] with a BIMS of 11, indicating R24 was cognitively intact. Medication teaching assessment completed 08/01/23 with the following two questions and answers: Is the resident short term? No. Do they want to self-administer medications? No. Medication orders: Tylenol Oral Tablet (Acetaminophen) Give 1000 mg by mouth three times a day for PAIN with start date of 08/10/23 and scheduled on Medication Administration Record (MAR) 0800, 1200, 2000. MAR shows medication administration was completed or attempted since order start date through date of survey. On 03/04/24 at 12:15 PM, Surveyor observed R24 sitting in recliner in room with bedside table positioned next to chair. Surveyor introduced self and asked R24 permission to interview. R24 agreed. Surveyor observed a medication cup with two oblong white pills inside. Surveyor asked R24 if the pills were medications. R24 stated they were R24's Tylenol. R24 stated that R24 must take them 3 to 4 times a day because of her arthritis pain. Surveyor noted the time and asked if the nurse had just given R24 those pills. R24 stated those two pills were given to her at morning medication pass at about 8 AM. Surveyor asked how often the nurse leaves the pills on her table like that and R24 stated, Whenever I ask them to. On 03/06/24 at 7:27 AM, Surveyor interviewed Registered Nurse (RN) C regarding procedure for residents to self-administer medications. RN C stated that RN C believes the nurse completes a medication self-administration assessment with resident to determine if a resident can safely take medications without supervision from nursing and then obtaining an order from the physician. If a resident is assessed to be safe, then an order is entered into the resident's electronic medical record (EMR) allowing the resident to self-administer medications. Surveyor asked RN C if there were currently any residents in the unit with a self-administration order. RN C responded that RN C didn't think so because if a resident has dementia, they are automatically determined to be unsafe. The self-administration of medications assessment in the chart will be answered 'no' to the resident wanting to self-administer. RN C stated that RN C personally never leaves meds in room with residents with dementia or other memory impairment. On 03/06/24 at 10:32 AM, Surveyor interviewed Certified Medication Assistant (CMA) D regarding procedure for residents self-administering medications. CMA D stated there is an assessment completed by the nurse in the EMR and a physician order stating a resident can self-administer medications. Surveyor asked CMA D if there were any residents currently in the unit that had a self-administration order. CMA D stated that CMA D wasn't sure, but CMA D does not let any resident self-administer meds unless this is completed. Surveyor asked CMA D if CMA D left any medications in cups in resident rooms at bedside during her shift on 03/04/24. CMA D denied doing so and stated the night shift sometimes does because CMA D has found medications on residents' bedside tables during CMA D's medication pass and discards them immediately. On 03/06/24 at 11:31 AM, Surveyor interviewed Director of Nursing (DON) B regarding the expectation and procedure for leaving medications at bedside for residents that are not assessed to self-administer medications. DON B stated the expectation is for the nurse to complete a medication teaching assessment within the EMR upon admission, readmission, and any other time the nurse deems appropriate.

Based on interviews and record reviews, the facility did not ensure their designated Infection Control Preventionist (ICP) completed training in infection control (IC) prior to assuming the role, without oversight by another IC trained individual. This has the potential to affect all 83 residents in the facility. This is evidenced by: An ICP is an essential component of an effective infection control program and is the person designated by the facility to be responsible for infection control. The Centers for Disease Control and Prevention (CDC), CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings updated October 2022, states in part, . Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered . Assign one or more qualified individuals with training in infection prevention and control to manage the facility's infection prevention program . On 03/05/24, Surveyor requested ICP E's professional credentials and the IC training. ICP E has a Wisconsin licensure as a Registered Nurse and a Master's degree in Gerontology. At 11:18 AM, Surveyor interviewed ICP E asking about IC training. ICP E stated that ICP E had not yet completed the training for IC and that, at the present time, there was no staff with the IC training that is overseeing her. ICP E assumed the role of ICP in September 2023, when the sister facility's ICP, who was overseeing this facility's IC program, resigned from the position. ICP E has not yet completed training in IC and is planning to begin the Centers for Disease Control and Prevention's (CDC) Infection Control Preventionist training next week.

Based on observations, interviews and record review the facility did not ensure that 4 of 8 sampled residents (R2, R3, R7 and R8) were free from physical and/or mental abuse. R1, who was admitted on [DATE], displayed increasingly aggressive behaviors including throwing furniture, pounding on peers' doors, striking staff, visitors and 2 peers. The facility put into place an approach of keeping R1 in sight while he was out of his room. This approach was ineffective in keeping residents safe. R3 was physically attacked by R1 and reported he no longer went to the dining room and did not sleep well due to his fear of R1. R8 reported feeling vulnerable and no longer sleeps in bed. R8 reports she sleeps in her recliner because it cannot be seen from the door. R2 was stuck by R1 while in bed and had an abrasion to his face. Prior to discharge, R7 reported being fearful of R1. This is evidenced by: R1 was admitted from the hospital on [DATE] for short term rehabilitation following a fall and urinary tract infection. Prior to hospitalization R1 had been residing in an apartment by himself. R1's [DIAGNOSES REDACTED]. R1's Minimum Data Set Assessment ((MDS) dated [DATE], indicates a BIMS (Brief Interview of Mental Status) of 9/15 (moderate cognitive impairment). R1 has had a Guardian of Person (Daughter) since 04/04/18. Protective Placement is being pursued. Surveyor review of R1's medical record reveals the following Nurses Progress Notes: 1. 08/02/19 19:09 (7:09 p.m.) Late entry. Resident was aggressive to staff and entering other resident rooms . 2. 08/03/19 03:12 (3:12 a.m.) Resident has been experiencing a number of times leaving his room this evening (approximately 6) .resident back to attempt to enter other resident's rooms, prevented doing so he began to swing his walker overhand striking the doors repeatedly. Staff was able to convince resident to place walker on ground upright, but then he began to actively closed fist punch at staff repeatedly. Decision was made to contact[NAME]PD/EMS (police department/emergency medical services) to assist with the situation. Chair was brought to resident, while sitting, resident grasped fingers of staff member and attempted to hyperextend them . 3. 08/06/19 20:30 (8:30 p.m.) Late entry: Resident was aggressive through the PM shift. Resident was 1:1 with staff and he was refusing to take his medications. While staff was with the resident in the dining room the resident stood up and was walking with his walker when he threw his walker at the staff member who was 1:1 with the resident. The resident then saw another resident coming across the dining room going to visit his wife and the resident reached out and grabbed the second resident by the right wrist and the neck. The second resident (R3) had no injuries. (R3) stated that he did not feel safe here with the resident. The nurse who was doing the med pass was able to break the two residents apart. The aide who was 1:1 with the resident was able to get the second resident out the room and over to his wife's room . A statement from LPN-E (Licensed Practical Nurse) includes, .When I asked R3 if he was hurt, he had said that R1 had struck him on the arm multiple times before I had gotten there. CNA D also stated the same thing. R3 then stated 'I do not feel safe with that man here .I have heard similar reports from multiple residents here Rehab and LT (long term) alike.' .he has not been able to be redirected or calmed down for hours . The SW (Social Worker) documented, 08/07/19 9:00 a.m., Writer met with R3 to interview the events that occurred on 08/06/19. R3 said, 'All afternoon, he (R1) was arguing with someone in the dining room area. I don't know who .some woman. Twice R1 tried to come in my room and I told him to get the .out of here and he did .As I was getting further up the hallway I felt R1 jump on the back of my wheelchair behind me and then he grabbed around my neck. I pushed him off. Other than grabbing my neck, he must have nails because he scratched my arm. I called for help and a big guy, who works here, came right away and helped. It was scarier than when it happened.' Review of R3's medical record reveals R3 was admitted for short term rehabilitation on 07/16/19 following a lawn mower accident. R3's record reveals that R3 has multiple fractures of his Pelvis with a stable disruption of pelvic ring. Review of R3's Minimum Data Set ((MDS) dated [DATE] indicates that R3 has a BIMS (Brief Interview of Mental Status) of 15/15 (cognitively intact). On 08/26/19 at 9:25 a.m., Surveyor spoke with R3 in his room. R3 was observed seated in a high backed wheelchair. R3 said that he came to the facility after tipping his lawn mower over and sustaining pelvic injuries. R3 said he has multiple cracks of his pelvis on both sides. R3 said he was in his wheelchair going to his wife's room and he saw R1 hit a staff person and then R1 came up behind his wheelchair and grabbed him around his neck and put his fingernails in his arm. I swung my arm to get him off and another staff came and got R1 off. R3 told surveyor that he was afraid of R1 and that everyone was. R3 said he couldn't sleep at night and that he quit going out to the dining room for breakfast. On 08/26/19 at 3:00 p.m., Surveyor spoke with CNA D. CNA D stated R1 was very quick, didn't like anyone invading his space and doesn't like people following him. CNA D said that R3 was very upset after this happened. On 08/27/19 at 9:15 a.m., the DON (Director of Nursing) told surveyor that R1 was to be on visual 1 on 1 when he is outside of his room. The DON said that this became effective after this incident on 08/06/19. 4. 08/09/19 at 20:05 (8:05 p.m.) R1 had forced himself between cart and writer and was using left arm, on side of body turned away from writer, so writer was unable to intervene .Resident was already angry and agitated, and then struck CNA G (who was assigned to provide 1 to 1 supervision) by a hard contact of backhand of left hand to CNA's upper right facial cheek .As CNA G was crouched on floor, and facing away from resident, Resident then tried to lunge toward unaware CNA .Resident ripped sign off wall, attempted to use eating utensils as weapons and then had a cover to food warming table in his hand, and attempting to use as a weapon, until police officers arrived and subdued resident themselves and assisting with transport to ER (emergency room ) . On 08/26/19 at 10:00 am., Surveyor spoke with CNA [NAME] CNA A said R1 could be combative, physically aggressive to residents and staff, throw his walker and chairs. CNA A said she knew that R1 had went into R2's room and hit R2 in the face. CNA A said that R1 had also hit R8's family member. CNA A said that R3 and R7 had expressed fear of R1. CNA A said that she had written a letter to the SSD (Social Service Director) and DON (Director of Nursing) informing them of these concerns. Surveyor review of R7's closed record reveals that R7 was admitted to the Rehab Unit on 06/05/19 and discharged on [DATE]. Review of R7's Minimum Data Set Assessment ((MDS) dated [DATE] indicated a BIMS (Brief Interview of Mental Status) of 15/15 (cognitively intact). R7's [DIAGNOSES REDACTED]. 5. On 08/26/19 at 1:20 p.m., Surveyor spoke with R8, 2 of R8's daughters and R8's husband. R8 was seated in a wheelchair, a recliner was observed in the corner not visible from the doorway and the bed was by the window visible from the doorway. R8's daughter said she had been visiting R8 recently and R1 had opened the closed door and tried to enter R8's room. R8's daughter stated she stood in front of R1 in an attempt to stop him from coming further in R8's room. R8's daughter said R1 began slapping her in the face and shoulders in response. R8's daughter said that she had instructed her mother to put her call light on to get help. R8 and R8's family members said CNA B had come to R8's room and R1 had hit CNA B in the face in response. R1 was to be on 1 to1 supervision at this time. There is no indication 1 to 1 was in place as R1 had time to open a closed door and strike R8's family before staff intervened. R8 told Surveyor she feels very vulnerable and that she sleeps in her recliner by the wall rather than her bed because R1 has wandered into her room and that she feels that R1 has gotten very dangerous. R8 said the recliner is behind the wall, not visible from the doorway. R8 said the R1 had come into her room several times. R8's family verified R8's fear and change in sleeping from bed to chair because of the fear. R8's daughter's said that they had went to the Administrator after this incident and had spoken to her about their concerns. Surveyor review of R8's medical record reveals that R8 was admitted on [DATE] for short term rehab following a displaced fracture of her right femur. Review of R8's MDS (Minimum Data Set Assessment)dated 07/17/19 reveals a BIMS (Brief Interview of Mental Status) of 15/15 (cognitively intact). Surveyor review of R1's nurse's progress notes in his medical record reveals the following note dated 08/17/19 at 12:44 p.m At approximately 1130 a.m. resident wandered into resident room number . CNA asked resident if she could fix his pants in an attempt to redirect out of the room and resident slapped her in the face and then slapped the visitor in the face . On 08/26/19 at 1:50 p.m., Surveyor spoke with CNA B. CNA B said R1 had slapped her across the face. CNA B said that when R1 was agitated they would redirect other resident away from him and shut resident room doors and try to keep people out of R1's space. CNA B said that R1 could become aggressive out of the blue, light a switch going off. On 08/27/19 at 9:05 a.m., Surveyor spoke with the NHA (Nursing Home Administrator). The NHA indicated that she had spoke with R8's daughters on 08/19/19 and told them a plan was in place for R1. The NHA stated the family expressed R8 was fearful. The NHA indicated they had offered a room change to another unit. The administrator said that one of the daughters had suggested a handbell be given to residents on the unit to alert staff for immediate help. The administrator said that this was done. Surveyor review of R1's nurses notes reveals the following entries: 6. 08/19/19 at 08:42 a.m. , R1 was witnessed by MD (Medical Doctor) striking male peer R2 as male peer lay in bed. Resident was immediately removed from room and seated at breakfast table without further incident. Message left with ADON C to update. 08/19/19 at 08:50 a.m., Resident (R2) was struck in the face, by male peer, as resident lay in bed. Peer was immediately removed from room. Noted resident with a 1 cm (centimeter) abrasion to his right lower cheek and a small abrasion just superior to that abrasion. Cleansed with soap and water and OTA (open to air). Message left for ADON C to update. MD aware. CNA I's written statement includes, On Aug. 19th at 8:15 a.m., I went to check on R1 to see if he was going to come to breakfast. He wasn't in his room, He was in R2's room muttering something. As I was entering the room I saw R1 hit R2 on the right side of his face. R2 was asleep in his bed before R1 hit him. I then said 'Hey you can't do that!' R1 turned around and said 'why not?' then casually strolled out of the room and .was able to direct him to breakfast. R1 was supposed to be on visual one to one when out of his room at this time. There is no indication 1 to 1 supervision was being provided as R1 was able to enter R2's room and strike R2. R2's medical record reveals that R2 was admitted from the hospital to the nursing home on 08/15/19. R2's [DIAGNOSES REDACTED]. Review of R2's most recent Minimum Data Set assessment dated [DATE] reveals that R2 has a BIMS (Brief Interview of Mental Status) of 1/15 (severe cognitive impairment). After this incident the facility developed a Crisis Plan for R1. The Crisis Plan is dated 08/19/19. The plan indicates that if resident is displaying aggressive behaviors call the police department and emergency medical services, call the crisis center for assessment and then the crisis center can assess resident at the emergency room and contact Winnebago Mental Health Institute and Mendota Mental Health Institute. Review of R1 record reveals that on 08/21/19 resident was sent to the emergency room and then sent to Geriatric Hospital Unit. The record also reveals that on 08/22/19 R1 was transferred to Winnebago Mental Health Institute due to aggressive behaviors towards patients at the hospital. On 08/27/19 at 9:05 a.m., Surveyor spoke with the NHA and DON. The NHA and DON indicated that they have been trying to find alternate placement for R1, had some assisted living providers looking and Inclusa (managed care) looking for placement also. The NHA said that R1 had multiple medication changes and emergency room visits in an attempt to determine possible reasons for the escalation in behaviors. The NHA was asked why R1 was able to enter R2's room and strike R2 if R1 was on visual one to one monitoring when out of his room. The NHA indicated that staff did not get there fast enough.

Based on observation, interview, and record review the facility did not consult with a physician when 2 of 31 sampled residents (R31 and R150) experienced a change in condition requiring alteration to their care. R150 had admission orders [REDACTED]. R150 routinely exceeded the fluid restriction. R150's weights continued to increase, and she experienced shortness of breath and low oxygen levels. There was no consultation with the physician despite the change in condition. R150 was transferred to the hospital after being seen by the nurse practitioner and was diagnosed with [REDACTED]. R150 was hospitalized for [REDACTED]. R31 has a [DIAGNOSES REDACTED]. Staff did not consult with the physician during this change in condition. R31 was subsequently hospitalized and given IV diuretics to take the excess water out of her system and lungs in order for her heart to work properly. This is evidenced by: Example 1: R150 was admitted on [DATE] with [DIAGNOSES REDACTED]. The most current MDS (Minimum Data Set) dated 1/15/19 indicated R150: ~Had a BIMS (Brief Interview For Mental Status) score of 15 indicating R150 had no cognitive impairments; ~Required extensive to total assistance of 1 to 2 staff persons for all aspects of care except eating; and ~Had shortness of breath with exertion and when lying flat. R150's nutritional care plan was dated 1/11/19 and included approaches of .Daily wt's (weights), monitor and report significant changes .Monitor and report s/sx (signs and symptoms) of [MEDICAL CONDITION] exacerbation .2.0 FR (2000 cc fluid restriction) . Surveyor completed a review of R150's hospital discharge instructions dated 1/8/19. The discharge instructions included, .Call Your Doctor If You Have Any Of There Symptoms .More trouble breathing with rest or activity .More shortness of breath when lying down .More fatigue with your normal level of activity .Gained 2-3 pounds in 1-2 days or 5 pounds in one week .More swelling in your feet/ankles or legs . Surveyor completed a review of R150's weights, fluid intake, and nursing notes and noted the following. All weights are noted in # (pounds). ~ 1/8/19, 360# ~ 1/9/19 368.3#. R150 was 640 cc's over the 2000 cc fluid restriction. In 1 day R150 gained 8.3 pounds. There was no indication R150 was re-weighed. The physician was not contacted. ~ 1/10/19, 369.1#. Fluid intake exceed restriction by 320 cc's. In 2 days, R150 gained 9.1 pounds. On 1/10/19 R150 was seen by a physician. physician progress notes [REDACTED].Lungs .clear .Extremities .bilaterally with trace [MEDICAL CONDITION] (minimal) .I did notice that she had gained 9 pounds so this will need to be monitored. She is at risk for recurrent weight gain .oxygen levels have been good . ~ 1/11/19, 370.7#. Fluid intake exceeded restriction by 1480 cc's. In 3 days, R150 gained 10.7 pounds. R150 also consistently exceeded the fluid restriction. The physician was not consulted. ~ 1/12/19, 372.1#. Fluid intake exceeded restriction by 1610 cc's. R150 gained an additional 1.4# in 1 day to a total weight gain of 12.1 pounds in 4 days. R150 continued to exceed the fluid restriction. There was no indication the physician was contacted. From 1/8/19 to 1/12/19 there were no nursing notes indicating a comprehensive clinical fluid assessment had been done which included an assessment of R150's weight gain and exceeding R150's fluid restriction. ~ 1/13/19, 369.5. Exceeded fluid restriction by 840 cc's. ~ 1/14/19, 376.2. Exceeded fluid restriction by 880 cc's On 1/14/19 a nursing note indicated, .O2 (oxygen) on RA (room air) was 56% after coaching to breath deeply and NC (nasal cannula) on at 2L (2 liters) O2 increased to 91%. An O2 saturation of 56% indicated R150 was significantly hypoxic and not getting enough oxygen. There is no evidence the physician was consulted. ~ 1/15/19, 370.8#. Exceeded fluid restriction by 1380 cc's. ~ 1/16/19, 382.9#. Exceeded fluid restriction by 1280 cc's. By 1/16/19 R150 had gained 22.9 pounds since admission, continued to exceed her fluid restriction, and had periods of significant [MEDICAL CONDITION]. Despite that, the physician was not contacted. From 1/12/19 to 1/16/19 there were no nursing notes indicating a comprehensive clinical fluid assessment had been done including an assessment of R150's weight gain and being consistently over the fluid restriction. ~ 1/17/19, 384.2#. Exceeded fluid restriction by 1060 cc's. R150's weight again increased by an additional 1.3 pounds, indicating a total weight gain of 24.2 pounds in 9 days. On 1/17/19, RD-C (Registered Dietician) faxed R150's physician. The fax indicated R150 had a 24 pound weight gain since admission. The fax also indicated R150 was exceeding her fluid restriction. This was the first time since 1/10/19 that a physician was notified of R150's weight gain and continuing to exceed her fluid restriction. The physician contact was completed by the RD and not nursing personnel. On 1/18/19 the physician changed R150's diuretic regimen. ~ 1/18/19, 384.0#. Exceeded fluid restriction by 1660 cc's. ~ 1/19/19, 387.4#. Exceeded fluid restriction by 1120 cc's. Despite changes to R150's medication regimen, R150 continued to gain weight. Since the physician was contacted on 1/17/19, R150 gained an additional 3 pounds in 2 days to equal a total weight gain of 27.4 pounds. The physician was not contacted. ~ 1/20/19 387.3#. Exceeded fluid restriction by 2200 cc's. ~ 1/21/19 386.8#. On 1/21/19 R150 was seen by a NP (Nurse Practitioner). The NP's progress note indicated, .Reason For Visit .[MEDICAL CONDITION] .is managed by the heart clinic .Since admission patient has gained approximately 25 pounds .she was noted to have oxygen saturations in the 70's - 80's this afternoon .heart failure clinic was notified of the weight gain .[MEDICAL CONDITION] .O2 sats (oxygen saturation) did improve after the nebulizer however feel this is likely related to fluid overload .continue to monitor closely . On 1/21/19 a nursing note indicated, .Weight gain of almost 27 lb (pounds) since admit on 1/8/19. [MEDICAL CONDITION] .pitting BLE (Bilateral Lower Extremities) .Noncompliant with FR (fluid restriction .Mild/moderate SOB (Shortness of Breath) this PM (evening shift) .SpO2 (peripheral capillary oxygen saturation) running in 70s-80s most of PM .Lungs diminished .Transferred to hospital for [MEDICAL CONDITION] . On 1/21/19 at 11:45 p.m., R150 was transferred to the local hospital and subsequently to a larger hospital in a nearby city due to cardiac concerns. Surveyor completed a review of hospital discharge records dated 1/28/19. The records indicated, .Decompensated diastolic [MEDICAL CONDITION] with failure of outpatient management .Acute on chronic hypoxic [MEDICAL CONDITION] . While hospitalized , R150 was seen by cardiology. A cardiology consult dated 1/22/19, .Since she was discharged , she has not been compliant with her volume restriction per the SNF (Skilled Nursing Facility) and patient is up approximately 26 pounds from her baseline weight .staff noted that her legs were becoming increasingly swollen and medication changes were made over the phone. Changes to her diuretics proved ineffective .noted increasing SOB .placed on [MEDICATION NAME] drip (a diuretic given intravenously) .fluid and salt restrictions .daily weights . On 2/07/19 at 11:15 a.m., Surveyor spoke with RN-J (Registered Nurse). Surveyor asked RN-J what the facility's practice was for notifying a physician of resident weights and when fluid restrictions were exceeded. RN-J stated some of the residents had parameters for physician notification. RN-J stated if no specific parameters were given, she would assess the resident for symptoms indicative of fluid overload and contact the physician. RN-J stated she did not assess weights and fluids daily. RN-J stated the RD did. RN-J stated the RD would let her know if a resident consistently exceeded their fluid restriction and if residents were having a weight gain. Surveyor asked RN-J about R150's weight and fluid restriction. RN-J stated she was not sure if R150 had parameters for physician notification. RN-J indicated however any resident with [MEDICAL CONDITION] should have daily monitoring of weights. RN-J stated the physician should be notified with any weight gain she thought was 5 pounds or greater in one week or 1-2 pounds in a couple of days. On 2/08/19 at 10:03 a.m., Surveyor spoke with RN-K. RN-K indicated the nurses should look at 24 hour intakes every day. RN-K indicted she would notify a physician if a resident was consistently over their fluid restriction over a couple of days. RN-K stated the RD was also very involved in monitoring fluids. RN-K stated the standard for physician notification of weight gain for residents with [MEDICAL CONDITION] was 3 pounds in 2 days and 5 pounds in a week. On 2/07/19 at 12:15 p.m., Surveyor spoke with RD-C. RD-C stated he as well as nursing looks at weights every day. RD-C indicated he monitored all residents on fluid restriction daily. RD-C indicated if he saw a resident exceeding their fluid restriction associated with increasing weights he would update the doctor. RD-C stated nursing could also update a residents physician. Surveyor asked RD-C if R150 had parameter for notifying R150's physician of weight gain. RD-C indicated he was not sure. On 2/08/19 at 11:33 a.m., Surveyor spoke with ADON-L (Assistant Director of Nursing). ADON-L indicated she was responsible for the unit where R150 resided. Surveyor asked ADON-L what the facility's practice was for monitoring residents with [MEDICAL CONDITION]. ADON-L stated typically any weight increase of 5 pounds in one week or 3 or more pounds overnight should have physician notification. ADON-L stated any resident with [MEDICAL CONDITION] who was admitted without parameters should have parameters clarified with the physician. On 2/08/19 at 12:22 PM Surveyor spoke with the DON (Director of Nursing). The DON indicated facility staff should be following the standard of care for monitoring cardiac residents with [MEDICAL CONDITION]. Example 2: R31 has [DIAGNOSES REDACTED]. On 7/31/18, the RD documented that he was unable to determine in a discussion with R31 what her usual weight was but did discover that R31 had not taken her diuretic when she was at home as it made her urinate too often. By 8/7/18, after taking the diuretic, R31 had lost approximately 83# from fluid loss. On 11/13/19 the physician documented R31 had continued to progress and the plan was to continue the diuretic. R31's physician her NP (Nurse Practitioner) saw her on 12/10/18 and 1/11/19 noted that her lungs were clear and her heart failure was stable and that her medications were to be continued. R31's weight on 1/7/19 was 299# and on 1/21/19 was 298.9#. On 1/22/19, R31 was seen by the NP. The NP documented R31 had a notable decrease in her [MEDICAL CONDITION], has looking bright and No respiratory distress or use of accessory muscles. R31's condition changed afterward according to the nurses' progress notes. On 1/23/19 in the evening a SBAR (Situation, Background, Assessment, Recommendation) was begun with documenting R31 complained of SOB (shortness of breath) and had oxygen saturation levels of 85% to 90%. The report was sent to the physician, however, there is no evidence of a response from the physician. On 1/23/19, during the night shift, LPN-M noted that R31 did not complain of SOB and that her lungs were clear. The note indicated R31 complained of pressure in her abdomen. This can be a symptom of [MEDICAL CONDITION]. On 1/24/19 on the day shift, RN-N documented R31 had a little SOB that seemed to be positional and that due to the size of R31's abdomen it could be pushing up on her diaphragm. Swelling of the abdomen and SOB when lying down are classic symptoms of [MEDICAL CONDITION]. There is no documentation of an assessment for [MEDICAL CONDITION] of her extremities. The facility has a copy of a fax that was sent to the doctor that day however there is no physician response found. On 1/24/19 on the night shift, LPN-O noted that R31 was weeping and worried about the swelling in her legs. The note indicated R31's lungs were clear but not heard very well in the bottom of her lungs. LPN-P noted that she did not complain to her about SOB but continued to need oxygen. LPN-P indicated she would pass on to the day shift to weigh R31 to alleviate her worries about the swelling in her legs and arms. There is no assessment of the [MEDICAL CONDITION] in R31's legs. On 1/25/19 at 9:37 a.m., R31 weighed 317.4#. At 12:25 p.m., a reweigh found R31 to weigh 315#. This is a 16.1# weight gain in 4 days. On 1/25/19 during the day shift, RN-H documented R31 continued to be monitored for SOB and a firmness in her abdomen. RN-H documented the 16# weight gain was over several days, R31 had not complained of SOB and did not have a cough. There is no assessment of her lungs. RN-H noted that the staff would weigh her daily and continue to assess. On 2/8/19 at 1:30 p.m. Surveyor interviewed RN-H about R31 and her assessment and follow through. RN-H stated she did an assessment of R31's lungs and they were clear but diminished at the bases. When asked if she had consulted with a physician when a 16.1# weight gain was identified, RN-H stated the ADON and Evening Supervisor had told her not to call the physician. On 2/8/19 at 1:30 p.m. Surveyor spoke with the ADON who did not recall such a conversation with RN-H. On 2/8/19 at 1:40 p.m. Surveyor spoke with the PM supervisor who did not recall a conversation related to this. The PM Supervisor said she would check her notes to confirm. No additional information was received. Record review continues: On 1/25/19 during the evening shift, LPN-Q noted staff continue to monitor R31 for complaints of SOB. LPN-Q documented R31's lungs were clear but diminished and R31's abdomen was hard. LPN-Q determined the plan was to continue to monitor R31. There is no assessment by an RN and no consultation with a physician. There was no weight documented on 1/26/19. On 1/26/19 during the day shift, LPN-P documented R31 had no complaints of SOB however her vital signs showed an increase in her pulse and a low grade temperature. There was no weight documented. During this shift, R31's oxygen saturation level went down to 75% (a critical level) but came back up with oxygen. There is no assessment by an RN during the day shift, however the plan was to have the evening nurse recheck R31's vitals and condition. There is still no consultation with a physician about her significant weight gain and the critical oxygen level when breathing room air. On 1/26/19 during the evening there is no cardiac assessment by LPN-O or an RN. LPN-O noted under the heading of Behavior that R31 was very worried about her legs and not being able to close them together in bed. There is no consultation with a physician. On 1/26/19 on the night shift, LPN-M noted that R31 had clear lungs and R31's breathing appeared regular. LPN-M noted [MEDICAL CONDITION] to R31's legs however there was no comparison to her usual condition and a round and firm abdomen. The LPN did not consult with the physician but rather determined the plan was to monitor R31. On 1/27/19 at 9:21 a.m., R31's weight was 320#. This is an overall weight gain of 21.1# in only 6 days. On 1/27/19 LPN-P consulted a physician and she was transferred to the ER or her weight gain, increased SOB, low oxygen levels, and her temperature. The hospital physician note on 1/27/19 indicates she was at the ER because of a 21 pound weight gain with worsening shortness of breath and [MEDICAL CONDITION]. The notation summarizes her condition as Over the last 2 to 3 days because of worsening dyspnea (difficultly breathing) she has been placed on supplemental oxygen by nasal cannula. As her symptoms were worsening and her weight was noted up 21 pounds, she was advised to present to the emergency room for further evaluation. The physician's impression was Acute systolic heart failure: Evidence by weight gain, [MEDICAL CONDITION] on top of her [MEDICAL CONDITION], increased fluid intake over the last several weeks, worsening dyspnea both with lying down as well as activity and decreased exercise tolerance, significantly elevated BNP (B-type natriuretic peptide) greater than 10,000 and a new onset flow murmur. R31 was admitted with telemetry and IV [MEDICATION NAME], a fluid restriction and echocardiogram and daily weights. Of note is the new heart murmur found was a murmur from her heart to her carotid artery. The facility management also determined that staff missed critical symptoms and did not consult with a physician when R31 presented with symptoms of [MEDICAL CONDITION]. The facility also determined that R31's symptoms could possibly have been taken care of in-house rather than send her to the hospital. Despite identifying these issues, there were no steps taken to prevent recurrence.

Based on closed record review and interviews the facility did not ensure that 1 out of 3 sampled residents reviewed for treatment of [REDACTED]. Resident #2 was admitted Friday afternoon with a complex pelvic fracture and has a [DIAGNOSES REDACTED].#2 was receiving 3 different oral diabetic medications. The facility did not obtain blood sugar orders upon admission and there are no standing orders to do blood sugars for residents receiving oral medications. Three days later, around mid-morning, therapy reported to the nurse a change in condition. The RN (Registered Nurse) did not assess for possible [DIAGNOSES REDACTED] (low blood sugar). Ten hours later, the physician was in house and was notified that Resident #2 was not able to be aroused. The physician ordered a blood sugar which was 44 and administered [MEDICATION NAME] IM twice to raise the blood sugar. Resident #2 was sent to the emergency room and expired the next day. This is evidenced by: Surveyor # requested the facility policy and procedures for Emergency Diabetic Reaction Management dated [DATE] which stated: treatment for [REDACTED]. Assess resident's condition for the following signs/symptoms: .Weakness .Tremor .Personality change, Not able to awaken, Stupor . Treatment includes the checking of blood sugars, adminstration of fast acting carbohydrate, and rechecking blood sugars as well as contacting the physician. Resident #2 was admitted with [DIAGNOSES REDACTED]. Physician orders dated [DATE], include 3 oral diabetic medications: [REDACTED]~Sitagliptin 50 mg every day ~[MEDICATION NAME] 10 mg in the morning, 5mg at noon, and 5 mg in the evening ~[MEDICATION NAME] 1000 mg every day. The physician orders did not inlcude any blood sugar monitoring. There is no evidence that any nurse called the physician for clarification or orders to monitor blood sugars with these medication changes. Review of the facility's standing orders for Resident #2 included an area for Diabetes Mellitus which included direction to complete a fingerstick blood glucose monitoring if [DIAGNOSES REDACTED]/[MEDICAL CONDITION] is suspected. Review of interdisciplinary notes: ~[DATE], Resident arrive to facility around 4 p.m. .O2 Sat (oxygen saturation) was 87% on RA (room air). O2 orders for 2L (liters) to keep O2 SATs > (greater than) 85%. Lungs diminished but clear bilaterally . ~[DATE] at 6:26 a.m., .Upon assessment 02 sat was 80% .was started on oxygen and sats leveled out at 90% for the remainder of shift . ~[DATE] at 3:37 p.m., OT (Occupational) Therapy documented: .c/o (complained of) dizziness and had to sit for extended period .Throughout entire session PT (patient) had episodes of 'blank stare and jerking of arms' --nurse informed. ~[DATE] at 4:18 p.m., PT (Physical Therapist) documented: Pt. very droopy eyed, lethargic and had great difficulty responding verbally to questions. Pt unable to stay awake during session . These are symptoms of [DIAGNOSES REDACTED] (low blood sugar). Nursing did not assess the resident's blood glucose level. On [DATE] at 3:15 p.m., Surveyor # interviewed OT-A who stated that on [DATE], therapy was completing Resident #2's treatment around 9:30 a.m. when she noticed the change in condition. OT-A indicated this was reported to RN-B (Registered Nurse). Interdisciplinary notes continue: ~[DATE] 1:41 p.m., Skin Team Review documented: .today noted with very limited mobility and confusion present . ~[DATE] at 1:14 p.m., Care conference was held with Resident #2 and 2 daughters. A note indicated: Resident presents with a flat affect and reports feeling foggy. This may be related to the scheduled [MEDICATION NAME] tablets. Resident also presents with a hoarse voice and audible respiratory congestion noted. This writer did update resident's nurse on findings and requested that MD (medical doctor) be updated . There is no evidence that the physician was notified or that a blood sugar was completed to rule out symptoms of [DIAGNOSES REDACTED]. ~[DATE] at 11:24 p.m. RN-C documented: Resident noted to be lethargic in afternoon, sleeping very sound in room .Approached resident at 2020 (8:20 p.m.) and resident still sleeping and unable to arouse. Vital signs at that time noted with respirations of 5/minute, all other vital signs stable. (Physician) present at facility and notified. Blood sugar also checked at this time and noted to be 44. Two IM (intramuscular) injections of 1 mg [MEDICATION NAME] each given per order with no arousal. Blood sugar upon F/U (follow up) 79. Started on IV (intravenous) D5 fluid at 100 ml/hr per (physician's) order. Resident still unable to be aroused. (Physician) gave order to send resident to ER (emergency room ) for further evaluation. At this time Resident's O2 sat dropped to 64%. O2 increased to 5 LPM (liter per minute) and O2 sat increased to 77%. Placed on High Flow O2 when paramedics arrived . Therapy first reported a change in condition (s/s of [DIAGNOSES REDACTED]) at 9:30 a.m. There was no RN assessment that included blood sugar monitoring and no physician consultation until the physician assessed the resident at 8:20 p.m. (10 ,[DATE] hours) later in which the blood sugar was 44. Subsequently the resident was sent to the hospital and expired the next day. On [DATE] at 1:00 p.m., Surveyor # spoke with the Director of Nurses (DON) who stated oral diabetic medications are monitored by each physician, more individualized. DON stated that Resident #2 was admitted late Friday afternoon so no blood sugar monitoring was implemented on Saturday or Sunday. This facility has no protocol regarding monitoring oral medications unless the physician orders it.

Based on observations, interviews, and record reviews, the facility did not ensure that 6 of 15 sampled residents were provided with adequate supervision and assistance devices to prevent accidents, leading to the potential for fractures and serious head injuries. Resident #3 has a long history of falls and has had 15 falls since July 2010. Resident #3 hit her head in 6 of these falls. The facility did not always investigate falls for root cause, did not update the resident's care plan with new interventions and approaches to prevent reoccurrence and, at times, did not follow through with the interventions that were put in place. Many times staff continued to rely on approaches that had already proven to be ineffective or on alarms, even though staff were not able to respond quick enough. Resident #11 had a fall from her glider rocker in her room on 09/04/10, which resulted in a fractured nose. The recommendation of the interdisciplinary team was to remove the glider rocker and obtain a different chair for her room. This was not done. On 11/18/10, it was observed that Resident #11 was sitting in her glider rocker at the edge of the rocker, and this was felt to be unsafe. A half an hour later Resident #11 fell out of her glider rocker, putting her at risk for serious injury. Resident #1 has a long history of falls. Resident #1 fell on [DATE] and was sent to the emergency room for sutures on her head (left hairline) and bruise to left forearm with a skin tear to her left elbow glued. Resident #1's medical record does not have details of the circumstances of the fall on 08/25/10, including the assessment and follow-up. Resident #2, who has a history of falls, fell on [DATE]. It was discovered that her alarm box was not plugged in, therefore staff were not alerted to her movements and attempts to get up prior to her fall. Resident #5 was walking with a restorative aide on 10/20/10 and was lowered to the floor. The facility did not recognize this was a fall. No Falls Circumstance Assessment and follow-up occurred as a result of this. Resident #14 had a fall on 11/01/10, while in the central hub of the building. This fall resulted in a pubic ramus fracture. The complete assessment of possible injuries from this fall is not noted in the clinical record. The facility's failure to have a system in which it critically analyzed each fall to determine the root cause, to determine if care planned interventions had been implemented and to determine if other interventions were needed to prevent or to reduce the probability that further falls would occur, placed residents in a situation of immediate jeopardy beginning 8/6/10. The facility was notified of the immediate jeopardy on 1/25/11. The facility removed the jeopardy on 1/26/11; however, the deficient practice continues at a scope/severity level of E (potential for harm that is not immediate jeopardy/pattern), because the facility still has staff to train and needs to evaluate the effectiveness of the interventions put in place. This is evidenced by: On 01/20/11 at 10:00 a.m., Surveyor # spoke with the DON (Director of Nursing) and asked what the facility protocol was after a resident has a fall. The DON said when a resident falls, the nurse does the assessment (vitals, range of motion, check for pain, talk to the resident regarding any injuries etc). The DON said that this assessment would be documented in the interdisciplinary progress notes or on the Falls Circumstance Assessment, which are both part of the clinical record. The DON said that if the resident is able to get off the floor and makes attempts to get off the floor, the Medi Lift is not used, otherwise the Medi Lift is always used. The DON said that the Falls Circumstance Assessment is always routed to her and these falls are always discussed by the IDT which includes the department heads and therapy staff. The DON said that the responsibility for follow-up is given to the department that is responsible to implement the approaches. The DON said that if there is a therapy screen request, this is given to the therapist at the meeting or a form is filled out. The DON said that she updates the care plans with any new approaches. The DON said that if a resident has personal alarms they cannot be left alone in the bathroom, and that the alarms should be transferred to other chairs (recliners etc.). The DON was asked what the facility system is for checking the functioning of personal alarms. The DON said that when staff transfer the alarms from one place to another (bed, chair, sensor pad) they are checked. Example #1: Resident #3 was admitted to the facility on [DATE]. The "Accumulative [DIAGNOSES REDACTED]. Resident #3 also has a history of Urinary Tract Infections. Resident #3's care plan dated 2/1/10, includes a problem of, "12/24/07, Impaired mobility and safety awareness r/t (related to) dementia, frequent falls, dx (diagnosis) of restless leg syndrome and age related weakness...Does not recognize risk behaviors." Interventions include, "Provide bowel and bladder program to meet resident's needs. Educate on safety awareness. Reminders as needed. Assist with transfers. Evaluate for acute illness. Maintain safe environment. Adequate lighting. Call light within reach at all times. Ensure proper footwear. Adaptive equipment PRN (as needed). Assess pain management PRN...PT (Physical Therapy) eval (evaluation)/screen as needed. Frequent reminders to use the call light for assistance with transfers..." The interventions also include the use of alarms in the wheelchair and other chairs, bed alarms, alarming mats alongside the bed, a motion monitor at bedside, and a low bed. Resident #3 was admitted to Hospice on 03/12/10 with additional [DIAGNOSES REDACTED]. Surveyor # located and reviewed Resident #3's Hospice Care Plan on 01/24/11. The "Team Care Plan as of 09-16-2010" includes the following interventions for falls: "3-15-2010 Wear proper footwear: shoes or non-slip grip footwear. NO slippers or bare feet. 3-15-2010 Provide assistance with toileting, transfers, and walking: before and after meals, and at bedtime... 3-16-2010 Volunteer request between 3 pm - 5 pm as often as possible to sit with patient. 3-23-2010 Low bed with floor mats. Reclining w/c (wheelchair) when patient too weak/tired to sit in regular w/c. Regular w/c when patient able to safely propel self..." The MDS (Minimum Data Set) assessment dated [DATE], indicates Resident #3: -Has short and long-term memory problems; -Has severely impaired daily decision making skills; -Can sometimes understand others; -Makes repetitive physical movements; -Requires limited assistance of 1 person with transfers; -Requires extensive assistance of 1 person for toileting; and, -Is occasionally incontinent of bladder and on a toileting program. Surveyor # reviewed Resident #3's medical record and facility documentation as well as interviewed the DON related to Resident #3's falls. The following was discovered: A. 7/8/10, IDT Notes state, "Resident being toileted by CNA (Certified Nursing Assistant) this am (morning) in the shower room and CNA went to put her clothes down and she (Resident #3) attempted to self transfer off of the toilet and landed on her left side on the floor before CNA could get to her. She stated she bumped her head...Will continue to monitor closely. Alarms in place and no further attempts to transfer herself." No other immediate interventions were documented. The Falls Circumstance Assessment, dated 07/08/10, includes an area for staff to document "Immediate Interventions completed to prevent further falls." This was left blank. "The IDT review and final treatment plan" portion of the Falls Circumstance Assessment states, "7/9/10-Staff retraining." The Fall Risk Assessment scored Resident #3 at "38." According to the scale, 14 or higher is considered high risk. The facility provided a timeline of Resident #3's falls including actions that were taken following the fall. According to the timeline, Resident #3's Lexapro and Xanax (both anti-anxiety medications) were increased. On 01/24/11 at 3:30 p.m., Surveyor # spoke with the DON and asked about interventions put into place following the 07/08/10 fall. The DON confirmed that only interventions were to increase the anti-anxiety medications. When asked what specific retraining was done with staff, the DON indicated that she had nothing documented as to what was discussed. Review of Resident #3's past falls finds a similar incident occurred on 03/11/10. During that fall, Resident #3 was seated on a commode at bedside. The CNA was near Resident #3 removing the draw sheet from the bed. Resident #3 fell from the commode striking her right elbow and shoulder. There were no changes made to Resident #3's care plan following the 03/11/10 fall. B. 08/02/10, IDT Note states, "Resident to be noted to be in recliner with clip alarm attached to sweater. Heard resident call out and was noted to be sitting on the floor with seater off at 2320 (11:20 p.m.)...Resident returned to chair and sweater and clip alarm put back on...Was given Ativan...and monitored one on one for approximately one hour..." The Falls Circumstance assessment dated [DATE] (sic) indicates that the Immediate Intervention was, "pad alarm in chair when sitting - take clip alarm off." According to the IDT note, this was not completed. The IDT review and final treatment plan included "Clip alarm removed. Pad alarm placed." The Fall Risk Assessment scored Resident #3 at "23" or high risk. Review of Resident #3's care plan finds that "Pad alarm while sitting in recliner," was added, however, not dated. On 01/24/11 at 3:30 p.m., Surveyor # spoke with the DON. The DON indicated that the approach to use the pad alarm was added after the 08/02/10 fall. C. 08/06/10, IDT Note states, "Sustained fall at 1605 (4:05 p.m.). Did bump head. Noted red area to med forehead and bridge of nose from glasses..." The Falls Circumstance assessment dated [DATE] states, "Resident was working with clothes pins activity and dropped one on the floor then bent down and slipped out of w/c. Did hit forehead..." The assessment indicates that Resident #3 did not have appropriate footwear on at the time of the fall. Immediate Interventions included, "Shoes applied with rubber soles. Enc (encourage) resident to let staff pick up items off floor. Given different activity." Due to Resident #3's cognitive declines, a reminder to let staff assist would not be appropriate. The IDT review and final treatment plan states, "8/9/10 + (positive) Chem 9 - Will continue to assess." This indicated that Resident #3 was positive for a UTI (Urinary Tract Infection)." Fall Risk Assessment scored Resident #3 at "34." The facility's timeline includes approaches of, "UTI - Alarms, Fluids pushed." On 01/24/11 at 3:30 p.m., Surveyor # spoke with the DON about Resident #3's fall on 08/06/10. Surveyor # confirmed with the DON that Resident #3 did not have appropriate footwear on at the time of the fall. Surveyor # asked if staff were re-educated on following Resident #3's care plan. The DON indicated no one was re-educated. When asked about the IDT recommendations, the DON indicated that when Resident #3 has a UTI, her behaviors and falls are expected to increase. The DON confirmed that no new interventions were implemented. Review of Resident #3's past falls finds a similar incident occurred on 04/16/10 where Resident #3 fell out of her wheelchair and struck her forehead. The IDT recommendation was for Resident #3 to be screened by Occupational Therapy for appropriate seating. Surveyor # requested a copy of the screen and was provided with a 02/25/10 screen. On 01/24/10, Occupational Therapy informed Surveyor # that Resident #3 had not been on their workload since 2005 and that any screens would be completed by RN-K (Registered Nurse) who is the Restorative Nurse. Surveyor # requested a copy of any screen completed for Resident #3 after 04/16/10. No screen was provided. D. 08/13/10 IDT Note states, "Residents (sic) alarms were going off, when staff arrived in the room resident was sitting on the floor next to bed...Denies hitting head...Stated was going to the bathroom...15 minute checks started for 3 days..." The Falls Circumstance Assessment includes Immediate Interventions of "15 minute checks x 3 days..." The IDT review and final treatment plan states, "15 min checks - + chem 9. Being treated for [REDACTED].#3 at "21." The facility's timeline includes approaches of, "UTI - Alarms, Fluids pushed." E. 08/19/10 IDT Note states, "Resident attempted to self transfer to bathroom and was found sitting on floor at end of bed. Stated 'I need to go to the bathroom'...Bed was in low position with sensor alarm sounding when found...Kept stating, 'I need to go to the bathroom. Take me to the bathroom...' Will continue to monitor." Fall Circumstance Assessment finds the Immediate Interventions section was left blank. The IDT review and final treatment plan states, "8/23/10 Res currently using alarms she is unaware of her safety needs and cont (continues) to self transfer. Res is hospice d/t declining health. Family aware of res impulse moves. Res was just toileted 45 minutes prior to fall. Will look at B&B (bowel and bladder)." Fall Risk Assessment score Resident #3 at "22." The facility's timeline indicates, "8-19-2010--No changes in POC (plan of care). Alarm sounding." On 01/24/11 at 3:30 p.m., Surveyor # spoke with the DON regarding Resident #3's fall on 08/19/10. Surveyor # asked what actions were taken to "look at" Resident #3's bowel and bladder. Surveyor # asked if an assessment or a voiding pattern/diary was completed. The DON indicated that a full assessment was not done, and that staff would have reviewed the information already in the record to see if the toileting plan was still current. The DON confirmed that there were no changes made to Resident #3's care plan. This was the second fall in six days in which staff were not able to respond quickly enough to a sounding alarm. There is no documentation to indicate that staff evaluated the effectiveness of using alarms. A federal hearing decision noted that "...the alarm is useless as an assistance device if the staff member is too far from the resident when the alarm sounds to come to the resident's assistance and prevent the resident from falling. Consequently, in every case where an alarm is used as an assistance device, facility staff must be no more than, at most, a few seconds and just paces away from the resident in order for the resident to be protected adequately." (Bethel Center vs. CMS, 2006) F. 08/26/10, IDT Note states, "2330 (11:30 p.m.) Call light triggered by floor mat alarm. CNA found res on floor...Res was sitting on floor at foot of bed. Res stated that she was closing the door...Door closed partially per res request. CNA did leave door ajar in order to hear alarms. 2345 (11:45 p.m.) res alarm sounded and CNA found res sitting on floor mat next to bed. Res stated that she was going to shut door. Res at this time was becoming agitated...Will initiate 30 minute checks x72 hours..." The Fall Circumstance Assessment, dated 08/26/10 indicates, "30 min checks x 72 hours. Hospice nurse informed /visit...POC updated resident purposely puts self on floor. 1-1, close supervision at nurses desk this a.m." The IDT review and final treatment plan indicates that Resident #3's ABHR cream was increased. (ABHR is a cream containing Ativan, Benadryl, Haldol, and Reglan). Fall Risk Assessment scored Resident #3 at "27." The facility's timeline indicates, "X2 falls, increase in ADHR (ABHR) cream, 30 min checks x 72 hours. UTI present-No treatment." Review of the care plan found that the approach of 30 minute checks for 72 hours was added to the care plan on 08/27/10. On 01/24/10 at 3:30 p.m., Surveyor # spoke with the DON about Resident #3's falls on 08/26/10. The DON confirmed that Hospice increased the frequency of the ABHR cream as this helped to calm Resident #3. Surveyor # asked why Resident #3 was placed on 30 minute checks when the falls were 15 minutes apart. The DON did not reply. G. 08/27/10 IDT Note states, "At 2150 (9:50 p.m.) resident was sitting in recliner and lowered foot rest and sat on floor in activity area. Did not hit head...Wearing clog footwear. Soles and non skid but shoes were off at time of the fall..." The Fall Circumstances assessment dated [DATE], under Immediate Interventions states, "Put to bed. Has UTI that family does not wish to treat." The IDT review and final treatment states, "Res with UTI." On 01/24/11 at 3:30 p.m., Surveyor # spoke with the DON. The DON confirmed that no new interventions were implemented following the 08/27/10 fall. Resident #3 was to be on 30 minute checks at the time of this fall. Although this approach was proven to be in effective, no new approaches were added to the care plan. H. 09/05/10 IDT Note states, "At approx (approximately) 7:45 p.m., resident was in main bathroom by dining room trying to transfer self onto toilet, she sat on the floor, she did bump left side of head on sink. Staff unable to get to her in time before she fell ...Did place on 1/2 hour checks r/t poor safety awareness. Continues with alarms, concave mattress, low bed. Is reminded continually to left (sic) staff help her with transfers etc." The Fall Circumstances Assessment indicates an Immediate Intervention of 30 minute checks. The IDT review and final treatment states, "9/7/10 risk benefit docum (document) with family. Check for UTI." Fall Risk Assessment scored Resident #3 at "24." Review of the care plan finds that 30 minute checks for 3 days was added on 9/5/10. Of note, 30 minute checks were proven to be an ineffective approach as Resident #3 fell on [DATE] while on 30 minute checks. No other interventions were added to the care plan to address Resident #3's continued falls. On 01/24/11 at 3:30 p.m., Surveyor # spoke with the DON about Resident #3's fall on 09/05/10. The DON was asked to explain the risk benefit document. The DON indicated that she spoke with the family about the risks and benefits of removing alarms since it had been successful for other residents. The DON stated that the family declined the removal of the alarms. I. 09/11/10 IDT Note states, "Resident crawled out of bed this morning at 0740 (7:40 a.m.) attempting to self transfer while trying to get to the bathroom...She was incontinent of BM (bowel movement)..." The Fall Circumstance Assessment included Immediate Interventions of, "Assist to bathroom. Brought to day room for 1:1 supervision..." The IDT review and final recommendation states, "9/13/10 Staff education to toilet resident." An IDT note dated 11/05/10 states, "Late entry; falls from 8-27-10, 9-5-10, and 9-11-10 reviewed by IDT. During Aug/Sept (August and September) frequent falls occurring. Resident noted to have UTI, wishes for non-treatment...staff educated on increase toileting due to behaviors/mood. Will continue with comfort interventions as appropriate. POC appropriate." Resident #3's care plan was updated to include "Scheduled toileting: NOC (Night) shift - Every round. Day Shift - Upon rising, before and after lunch, end of shift. PM Shift - First round, before and after supper, HS (Hour of Sleep)." The facility's timeline indicates that Resident #3's toileting plan was discussed with staff. On 01/24/11 at 3:30 p.m., Surveyor # spoke with the DON and asked what staff used to determine that the care planned toileting schedule was appropriate for Resident #3. Surveyor # asked if the schedule was based on an assessment including a voiding pattern or diary. The DON stated that the schedule was not based on any assessment. J. 09/18/10 IDT Note states, "Resident found sitting on floor at 2000 (8:00 p.m.). Was leaning against bed and barefoot. Stated she had to go to the bathroom and didn't make it. Call light in place but is unable to comprehend use of call light due to dementia." The Fall Circumstance Assessment, dated 09/18/10 indicates that appropriate footwear was not in place and that Resident #3 was "barefoot." The description of the event states, "Res found lying on mat next to bed. Was leaning against bed which was in low position. Alarms failed to sound..." Immediate Interventions included, "Mat alarm replaced with clip alarm. No mat found to replace broken mat. Incontinence care after toileting. Motion alarm checked and was working..." The IDT review and final treatment stated, "9/20/10 Will try body pillow. Mat noted to be working. Clip alarm removed. Mat alarm tested several times and noted to be working..." Fall Risk Assessment scored Resident #3 at "32." An IDT note dated 09/20/10 states, "IDT review of fall from 9/18/10...Resident is noted to sleep on edge of bed and to have legs out of bed. Resident will have assessment for use of body pillow to prevent further falls." The facility's timeline indicates that the body pillow was placed. Review of Resident #3's care plan finds no intervention for the use of a body pillow while she is in bed. On 01/24/11 at 3:30 p.m., Surveyor # spoke with the DON and asked about the recommendation for Resident #3 to use a body pillow while in bed. The DON stated that the body pillow was placed, but Resident #3 refused to use it and threw it out of her bed. Surveyor # asked what intervention was tried after Resident #3 refused the body pillow. The DON indicated that there were no other updates to the care plan. K. 10/2/10 IDT Note states, "At 11:50 a.m., resident sitting at the table and attempted to put her arm up on the table and then out her head on her arm a (sic) she often does and she was not near enough to the table...She fell on to her forehead and knees...forehead with 1 inch aeration. Wound not gapping or deep. It was cleansed well and 3 small steri strips applied to laceration...Reviewed trial of Velcro belt if resident is able to remove for safety and POA (Power of Attorney) in agreement with velcro belt..." The Falls Circumstance assessment dated [DATE] indicates an Immediate Intervention of, "Velcro belt when up in w/c. Resident demonstrates ability to remove when asked to do so..." IDT review and final treatment states, "Velcro belt placed on w/c (wheelchair) res. hospice." Fall Risk Assessment scored Resident #3 at "35." Review of the care plan finds that the velcro belt was added as an approach. On 01/24/11 at 3:30 p.m., Surveyor # spoke with the DON. The DON stated that Resident #3 routinely removes the velcro belt and "Staff don't even put it on anymore." On 10/02/10, Hospice updated Resident #3's care plan to include, "Keep assistive devices within reach: walker, cane, wheelchair, reacher (specify all that apply)...Floor (motion alarm). Body pillow. Monitor frequently. Chair alarm when up in recliner. Belt while up in w/c for safety." L. 10/4/10 IDT Note states, "Resident being monitored for fall from the 2nd and now she fell again this afternoon toileting herself without assistance. She has a red mark to her right knee..." The Falls Circumstance assessment dated [DATE], does not include any evidence of Immediate Interventions. The IDT review and final treatment plan states, "Res using different w/c while hers was being repaired - able to release seat belt and self transfer res not aware of safety issues." The Fall Risk Assessment indicates that Resident #3 continued to be high risk for falls. An IDT Note dated 10/26/10 states, "Late entry for 10/5/10. IDT reviewed fall from 10/4/10. This resident has notable decline in health status. She has a velcro belt to remind her against self transfer. Resident is able to remove this ad lib. She also utilizes a personal alarm...Staff toilet resident frequently but she will continue to attempt to self transfer. She is also known to crawl out of bed onto floor as well..." The facility's timeline indicates that previous interventions continue and that staff are to toilet resident frequently. Review of the care plan finds no changes to Resident #3's toileting plan. On 01/24/11 at 3:30 p.m., Surveyor # spoke with the DON about Resident #3's fall on 10/04/10. The DON stated that Resident #3 was using a peer's reclining wheelchair while maintenance was installing the reclining mechanism on Resident #3's wheelchair. The DON stated that Resident #3 did not like the reclining wheelchair, so they opted not to pursue that as an approach. (Of note, the use of a reclining wheelchair was an approach on the Hospice Care Plan since 03/23/10.) The DON stated that staff reviewed the current toileting plan and found it appropriate. The DON verified that no bladder assessment, including a voiding pattern/diary, was completed. M. 12/13/10 IDT Note states, "Staff went to check on resident and was found sitting on floor by recliner in common area of special care unit. Fall unwitnessed..." The Falls Circumstance Assessment indicates that Resident #3 had a clip alarm on while in the recliner. The Immediate Intervention was to place a pad alarm in the recliner. The IDT review and final treatment plan indicates that a pad alarm is to be placed in chair when Resident #3 was sitting in the recliner or activity area. Resident #3 had a similar fall from the recliner while using the clip alarm on 08/02/10. The care plan was changed on 08/02/10 to indicate that Resident #3 requires a pad alarm while in the recliner. Staff did not implement Resident #3's care plan when they used a clip alarm while in the recliner on 12/13/10. The facility's timeline indicates, "...Removed clip (alarm)---Pad alarm in recliner." On 01/24/11 at 3:30 p.m., Surveyor # spoke with the DON about Resident #3's fall on 12/13/10. Surveyor # asked what new intervention was added following the fall. The DON stated that the pad alarm was added. Surveyor # pointed out that the pad alarm while Resident #3 was in the recliner, was added on 08/02/10. The DON reviewed the falls tracking list and said that she was not aware that Resident #3 had fallen from the recliner. Surveyor # asked what training was completed for staff related to following the care plan. The DON indicated that no training had been done. On 12/14/10, Hospice updated Resident #3's "Team Care Plan as of 01-24-2011" with the approach, "12-14-2010: Low bed and floor mats and motions alarms. Chair alarm for wheelchair and recliner." No new interventions are addressed as these same approaches are also listed on the "Team Care Plan as of 09-16-2010" with an implementation date of 03/23/10. N. 01/05/11 IDT Note states, "Resident fell during a self-transfer attempt to the bathroom at 1330 (1:30 p.m.) today. She had been toileted twice in the hour prior to the fall. Her alarm sounded, she sat in front of the toilet, smiling, said she did not bump her head and was not hurt...Resident will be reminded/encouraged to try to completely empty her bladder with void." The Falls Circumstance assessment dated [DATE] (sic) included Immediate Intervention of "...Encourage to sit longer to empty bladder more completely." The IDT review and final treat plan stated, "Will check bowel pattern and possible bladder scan." On 01/24/11 at 3:30 p.m., Surveyor # spoke with the DON and asked if staff had completed a bowel and/or bladder assessment. The DON indicated that a bladder scan was completed. Review of Resident #3's treatment sheets indicates that the bladder scans began on the evening shift on 01/06/11. The DON asked what immediate interventions were implemented to prevent Resident #3 from falling. The DON indicated no other interventions were implemented. O. 01/06/11 IDT Note states, "Resident was sitting in w/c arm's (sic) length away from table and slipped out of w/c at 1530 (3:30 p.m.), was witnessed fall and w/c alarm was sounding. Did strike head, small laceration noted on forehead...Did fall on left hip, range of motion intact...Per hospice, if resident is in common area, to be placed closer to table to prevent leaning over too far. Resident is able to unlock own brakes and propel self in w/c..." The Falls Circumstance assessment dated [DATE], Immediate Interventions state, "When resident is in common area per hospice to be put at table to prevent from leaning over too far." The IDT review and final treatment plan states, "Educate staff on possibly laying resident down if she allows or allow to rest in recliner." Review of Resident #3's care plan indicates, "Offer resident naps when tired or offer to rest in common area in recliner. Added 1/10/11." This is 4 days after the fall occurred. The Hospice "Team Care Plan as of 01-24-2011" includes an approach, "01-06-2011...Fall on 1/5 and 1/6 resulting in small abrasion to forehead. Patient tends to lean forward in w/c. Patient will now be placed at table when up in w/c." On 01/24/11 at 3:30 p.m., Surveyor # asked the DON what immediate interventions were implemented following the 01/06/11 fall. The DON indicated that hospice recommended that staff put Resident #3 up to the table. The DON stated that Resident #3 is able to lock and unlock her wheelchair breaks and propel the wheelchair independently. The DON stated, "So that (Hospice recommendation) won't work." On 01/24/11 at 9:40 a.m., Surveyor # spoke with CNA-H (Certified Nursing Assistant). CNA-H said Resident #3 is hard of hearing and it is difficult to communicate with her. CNA-H said Resident #3 uses a wheelchair and does propel it herself. CNA-H said Resident #3 is not able to walk very well and is very weak in the knees and that they do a pivot transfer on and off the toilet. CNA-H said Resident #3 is very quick, has had falls and when the alarms go off she is quick. CNA-H said Resident #3 sometimes does not sleep at night and when she doesn't she is up during the day. CNA-H said Resident #3 frequently has to go to the bathroom and will say that she needs go right after she has gone to the bathroom. CNA-H said that sometimes they do 1-1 with Resident #3 and that she is better/calmer when she has one-to-one and someone talking with her and going to the bathroom with her. On 01/24/11 at 11:30 a.m., Surveyor # spoke with RN-I. RN-I described Resident #3 as being very quick, difficult to redirect, falls because she thinks that she can walk, and sometimes has difficulty sleeping at night. RN-I said Resident #3 is followed by Hospice and usually hospice see's Resident#3 one to two times a week. RN-I said that since Resident #3 moved to her current unit in July 2010, she has never used a reclining wheelchair. Example #2: Resident #11 has [DIAGNOSES REDACTED]. Resident #11 is her own decision maker. Review of Resident #11's interdisciplinary progress notes indicates the following on 09/04/10: "Called to resident's room approx. 1130 (11:30 a.m.) to find resident sitting on floor with blood on floor and resident holding nose. Stated, 'I was rocking in my rocking chair and I just flew out.' Resident noted to have bloody nose with small cut on forehead. Ice pack applied to nasal/forehead area. Moderate bruising noted to bridge of nose. Call placed to on-call MD (Medical Doctor) with order to send out to ER (emergency room ) for eval (evaluation). Resident denied headache or soreness to back of neck. No immediate side effect of nasal congestion, but as assessments continued, resident then c/o (complained of) mild nasal stuffiness. Resident taken by ambulance to ER for eval. Family updated. Family will meet resident at ER. Neuro checks performed