Every finding on record at Pleasant View Nursing Home

Based on interview and record review, the facility did not ensure when COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized for 1 of 3 residents (R3) reviewed. R3 did not receive the 2025-2026 COVID-19 Vaccine. This is evidenced by: The facility's policy and procedure titled, COVID-19 Vaccination, implemented 11/10/25, states in part: Policy: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. Policy Explanation and Compliance Guidelines: 3. COVID-19 vaccination is recommended for the prevention of COVID-19 disease and its complications as follows: a. Adults ages 65 years and older: Vaccination based on individual-based decision-making. 5. For individuals who are not immunocompromised, refer to Table 1 for the 2025-2026 COVID-19 vaccination schedule details. 11. COVID-19 vaccinations will be offered to residents when supplies are available, as per CDC (Centers for Disease Control and Prevention) and/or FDA (Food and Drug Administration) guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period, or refuses to receive the vaccine. 13. The facility may administer the vaccine directly or the vaccine may be administered indirectly through an arrangement with a pharmacy partner or local health department.Table 1: 2025-2026 COVID-19 vaccination schedule, November 4, 2025. 1e: Ages 65 years and older. Previously vaccinated before 2025-2026 vaccine: Administer 2 doses of 2025-2026 vaccine. (Moderna, Novavax, or Pfizer-BioNTech). R3 was admitted to the facility on [DATE], is over the age of [AGE] years old, and has diagnoses that include the following: unspecified dementia - severe with agitation, primary hypertension (high blood pressure), atherosclerotic heart disease (plaque buildup in the arteries), and supraventricular tachycardia (heart rhythm disorder with a fast heartbeat). R3 was admitted to the facility on hospice and has an activated power of attorney (POA). R3 has documented COVID-19 vaccines on 1/20/21, 2/17/21, and 11/16/23. R3's Progress Note, dated 9/29/25, states: Call placed to daughter and POA.and she agreed to COVID-19 and flu vaccines. I will also contact Hospice for their approval. R3 received the influenza vaccine on 10/27/25; however, there is no further documentation regarding R3's COVID-19 vaccine for 2025/2026. On 3/24/26 at 10:54 AM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she was unable to find any information on the COVID-19 vaccine being administered to or declined by R3. DON B indicated she would have expected R3 to receive the COVID-19 vaccine after verbal consent was given by R3's POA.

Based on record review and interview, the facility did not offer each resident influenza immunization, and the resident's medical record does not include documentation the resident either received, refused, or was educated on the risks and benefits of the influenza immunization for 1 of 3 residents (R4) reviewed for immunizations. R4's Activated Power of Attorney (APOA) signed the consent for the influenza vaccine, and there is no evidence that R4 received the immunization. Evidenced by:The facility's policy titled Influenza Vaccination dated 7/1/25 states in part .7. Individuals receiving the influenza vaccine, or their legal representative, will be required to consent prior to the administration of the vaccine. The consent will be located in the resident's medical record. On 10/2/25, R4's APOA signed the facility's Influenza Vaccination Information and Release Form that states in part .I have read the above information about influenza and the flu vaccine, and the special precautions. I have had the opportunity to ask questions and understood the benefits and risks of flu vaccination. I request that the influenza vaccine is given to the person named below of whom I am the parent/ guardian or to me. Name of person to be vaccinated: [R4's name]. Signature of the person to be vaccinated (or HCPAO (Health Care Power of Attorney)/guardian: [APOA's name] . Surveyor reviewed R4's electronic health record and was unable to locate documentation of R4 receiving the influenza vaccination, despite having the signed consent. On 3/23/26 at 2:01 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if R4 received the influenza vaccination, DON B stated that they found the consent but are still looking for documentation the vaccination was administered. On 3/24/26 at 9:57 AM, DON B reported to Surveyor that they were unable to find documentation indicating that R4 had received the influenza vaccination. Surveyor asked DON B if there was a signed consent for the vaccination, would they expect that it be administered, DON B stated yes.

Based on observation, interview, and record review, the facility failed to immediately provide basic life support, including cardiopulmonary resuscitation (CPR) to a resident requiring emergency care for 1 of 3 residents (R1) reviewed for code status. This has the potential to affect 12 full code residents that reside in the facility. R1 is a full code and was found on the floor of his room unresponsive on [DATE]. A Registered Nurse (RN) failed to initiate CPR immediately, the facility failed to ensure that staff were competent in using basic life support equipment, and failed to ensure that there was always a CPR-certified staff member in the building.The facility's failure to provide immediate life saving measures to a resident who wished to have basic life support measures initiated such as CPR, failure to ensure that a CPR certified staff member was in the building at all times, failure to ensure all staff were aware of where lifesaving equipment was located and were able to demonstrate competency of basic lifesaving equipment in a code blue situation created a finding of immediate jeopardy that began on [DATE]. Surveyors notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on [DATE] at 4:33 PM. The immediate jeopardy was removed on [DATE]; however, the deficient practice continues at a severity/scope level of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. This is evidenced by:Per CMS (Centers for Medicare and Medicaid Services) Cardiopulmonary resuscitation (CPR) memo 14-01 revised [DATE], CPR refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased. When addressing full-code residents: If a resident experiences a cardiac or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition,) facility staff must provide basic life support, including CPR, prior to the arrival of emergency medical services.Facility policy titled, Cardiopulmonary Resuscitation (CPR), dated [DATE] with revision date of [DATE], states in part, .1. The facility will follow current American Heart Association (AHA) guidelines regarding CPR. 2. If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and. 3. CPR certified staff will be available at all times. R1 was admitted to the facility on [DATE] with diagnoses that include Pneumonia due to Pseudomonas, Other Non-specific Abnormal finding of lung field, Chronic Obstructive Pulmonary Disease unspecified, Weakness Unspecified, Essential Primary Hypertension, Malignant Neoplasm of the Prostate, and Anemia.R1's most recent Minimum Data Set (MDS) dated [DATE] states that R1 has a Brief Interview for Mental Status (BIMS) of 13, indicating that R1 was cognitively intact. The MDS also indicates that R1 required substantial/maximum assistance for all mobility and transfer needs.R1's Advance Directives dated [DATE] state that R1 chose to remain a full code. If found unresponsive, pulseless and not breathing, R1 wished to have CPR performed.R1's Care Plan dated [DATE] with revision date of [DATE] states, in part: I have emphysema/COPD (Chronic Obstructive Pulmonary Disease) related to history of smoking. Interventions include: Monitor for signs/symptoms of acute respiratory insufficiency, Anxiety, confusion, restlessness, Shortness of Breath (SOB) at rest, cyanosis (bluish discoloration of the skin), somnolence (excessive drowsiness) . I have oxygen therapy related to acute hypoxic respiratory failure (lack of oxygen), history of mass of right lung and COPD. Interventions include: Monitor for signs/symptoms of respiratory distress and report to MD (Medical Doctor) PRN (as needed): Respirations, Pulse oximetry, increased heart rate, restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (collapsed lung), hemoptysis (coughing up blood), pleuritic pain (chest pain due to inflammation of the lining of the lung), cough accessory muscle usage, skin color. Oxygen settings: O2 via nasal cannula at 1L/min at rest and 3L/min with activity. R1's Physician Orders include, in part:--CPR (Cardiopulmonary Resuscitation). Order Date: [DATE]. No end date.--Facility parameters for vital signs include O2 less than 88%. Order Date [DATE]. No end date.--Oxygen 1L/min at rest and 3L/min with activity via nasal cannula every shift. Order Date: [DATE]. No end date.--Portable oxygen for activities as tolerated. Order Date: [DATE]. No end date. R1's Progress Notes include:On [DATE] at 1:40 PM, RN/NCC M (Registered Nurse/Nursing Care Coordinator) Nursing Note: Per NP (Nurse practitioner): Resident at (Facility name). Resident developed hypoxemia while working with therapy today. He reported shortness of breath with standing and pivoting. Therapy checked his oxygen level and it was 73%. Oxygen via nasal cannula was increased to 4L, but still stating 74-76% . He denies any dizziness, lightheadedness, chest pain. He does have wheezing and edema. He has an appointment with oncology today and both resident and son really want to get him there. Ordered a one-time DuoNeb treatment and sats (oxygen saturation in blood) improved to 92%. Son transported him to appointment with portable oxygen. Electronically signed by NP G (Nurse Practitioner) on [DATE] at 12:10 PM. On [DATE], Physical Therapy Note: . Pt attempts stand transfer X2 (times two) attempts however pt. (patient) unable to come to full stand. Writer retrieves second assist. On 3rd stand pt. performs sit to stand moderate Assist X2 with pt. putting hands on walker. Pt stands with BUE (bilateral upper extremity) support on walker CGA (contact guard assist) while CNA (Certified Nursing Assistant) holds urinal for pt. to urinate. When pt. is done urinating writer cues pt. to pivot to w/c (wheelchair) with 4WW (four wheeled walker), pt. has difficulty picking up and pt. reports having a hard time breathing. Writer has pt. sit down in recliner chair. SPO2 (saturation of peripheral oxygen) taken 72%-76% on 3.5 L increased to 4L (liters oxygen). Writer does not leave pts room and asks CNA to notify NCC (Nursing Care Coordinator) regarding low O2 sats NP and NCC enter pts room. NP assess pt., son enters room while assessing pt. NP explains to son regarding O2 sats and offers breathing treatment before leaving for doctor appointment. Pt agreeable. Response to Tx: Pt reports severe exertion with transfers and standing. Pt assessed by NP during session for low O2 sats. Electronically signed by PTA P (Physical Therapist Assistant) at 3:54 PM. On [DATE], Occupational Therapy Note: Pt (patient) on 4L O2, had just received a breathing tx. (treatment) which increased his PO2 (pulse oximetry) from 72% to 92%. Pt required AX 2-3 (assist of 2-3) to transfer into vehicle with his son to go to oncology appointment. Electronically signed by OT Q (Occupational Therapist) at 2:41 PM. On [DATE], R1 was seen for an office visit at the (Name of oncology clinic.) R1's Oncology Note includes, in part: . Exam: Lungs have decreased air filling in the right upper lobe otherwise with good breath sounds bilaterally on 4L (4 liters) NC (nasal cannula) O2 (supplemental oxygen). Assessment: RUL (right upper lobe) bronchial narrowing that is likely the source of his respiratory difficulties and increased O2 needs. tenuous respiratory status. Vital signs: SpO2 87% .On [DATE] at 8:24 AM, Surveyor interviewed NP G (Nurse Practitioner) and asked if R1's hypoxic episode on [DATE] was a change in condition. NP G stated yes, R1 had not been that hypoxic before. Surveyor asked if an assessment should have been done following R1's return from oncology appt. NP G stated that NP G had not ordered further assessments, as NP G did not believe that R1 would return to the facility following the appointment. Surveyor asked if NP G felt that an assessment should have been performed by staff when R1 did return from the appointment. NP G stated yes, given what R1 was like before R1 left, NP G would hope so.Of note: There is no documentation of what time R1 arrived back to the facility after his oncology appointment. There is no documentation that any respiratory assessments or monitoring was completed upon R1's return to the facility.On [DATE] at 5:07 AM (Late Entry), RN D (Registered Nurse) Nursing Note: I last saw resident when I came over to. unit at 11:30 PM on [DATE]th. Around 2:00 AM-2:30 AM, CNAs answered residents call light he needed to use the bathroom. He sat on the edge of the bed and used his urinal. I was on break from 2:30AM - 3:00 AM. I started passing meds at 4:15 AM. I got to R1's room at 5:07 AM, his door was shut. I walked in to him face down laying right next to his bed on the floor. His head was at the base of the bed and feet at the top of the bed. He was slightly turned on his left shoulder. Arms were straight down next to his side. I walked over to him yelling his name and tried to flip him over onto his back. I noticed right away he had a laceration on his forehead. His face was slightly blueish in color. I immediately yelled for help. CNA R (Certified Nursing Assistant) came from another resident's room. I then ran to LPN E (Licensed Practical Nurse) who was the supervisor. to come up because the resident was on the floor and not breathing. As she ran down to his room I looked up on the computer his code status which was CPR. LPN E started CPR right away, CNA F dialed 911, the call went out at 5:13 AM. We did CPR until the police, fire dept, and ambulance showed up around 5:22 AM.Of note: per RN D's documentation above, RN D did not check R1's code status or initiate CPR immediately upon finding R1 down with his face slightly blueish in color. On [DATE] at 10:04 PM, LPN E (Licensed Practical Nurse) Nursing Note: Late entry for [DATE] at 0500 (5:00 AM). Writer was. starting 0600 (6:00 AM) medication pass. Second Floor RN (Registered Nurse) came to writer frantically stating that resident was on the floor in his room unresponsive. Writer immediately locked medication cart and came to the resident's room. Resident was face down on floor with top of head towards window next to his bed. Writer felt for a pulse. No pulse was found. Second Floor RN stated that he was a full code. Writer immediately rolled patient from prone to supine position and initiated CPR. CNA called 911 about PNB (pulseless non-breather) with CPR in progress. (Town name) . EMT (Emergency Medical Team) entered room and began prepping resident. [NAME] Deputy immediately followed EMT and took over compressions from writer. EMS (Emergency Medical Services) followed within 2 minutes. EMS continued lifesaving efforts. Writer let the EMS and (Town name) Fire Department continue with life saving measures at that time. Writer went to first floor and contact [sic] DON B (Director of Nursing) at 0536 (5:36 AM) to inform her of PNB and CPR in progress for resident. Efforts to continue lifesaving efforts for resident were ceased. Coroner called. On [DATE] at 2:20 PM, Surveyor interviewed CNA F who indicated that on [DATE] at a little past 5:00 AM, CNA F was working with a resident when RN D came to the room and said that R1 was on the floor. CNA F indicated leaving the resident and going to R1's room and noting R1 on the floor face down. CNA F indicated RN D stated RN D needed to get LPN E and left the room. Surveyor asked if RN D gave any instructions prior to leaving the room. CNA F stated no. CNA F indicated CNA F remained with R1, checking for responsiveness by rubbing R1's back. CNA F indicated CNA F recalls hearing that R1 was a full code, turning R1 over onto his back, and LPN E starting compressions. CNA F called 911. Surveyor asked CNA F who can perform CPR. CNA F stated everyone is supposed to, but staff looks to the nurses to do it. CNA F stated CNA F is not current in CPR certification. Surveyor asked how much time elapsed between CNA F arriving in R1's room and LPN E starting compressions. CNA F stated about 4-5 minutes.On [DATE] at 12:11 PM, Surveyor interviewed LPN E and asked about low oxygen levels. LPN E stated LPN E would check orders, turn up the oxygen level and notify the provider. LPN E indicated need to go back and recheck oxygen levels within 30 minutes to ensure resident is doing OK and then performing follow up assessments. Surveyor asked about R1. LPN E stated on [DATE], LPN E was the supervisor and RN D was working on the second floor. LPN E stated RN D came to the first floor where LPN E was about to pass medications, and RN D stated R1 was on the floor and unresponsive. LPN E indicated both nurses went up to the second floor to R1's room and LPN E checked for a carotid pulse and found none, then asked for R1's code status. LPN E stated RN D left the room to go to the computer and returned stating full code. LPN E then began compressions and told a CNA in the doorway to call 911. LPN E stated they needed an ambu bag, so RN D took over compressions. LPN E stated LPN E couldn't recall where the ambu bag would be, so looked around and found one in the locked medication room. LPN E stated on return to R1's room, LPN E tried giving breaths, but it wasn't working properly, so they did another switch and LPN E resumed compressions. LPN E stated EMS arrived and took over care. LPN E left the room, called DON B to report, and went back to first floor. Surveyor asked about emergency supplies. LPN E stated LPN E did not call for or obtain the AED or the emergency bag by elevator 2. LPN E indicated having no knowledge of what is contained in the emergency bag and stated there was never really any education on that.On [DATE] at 10:25 AM, DON B (Director of Nursing) Nursing Note: Resident was found by nursing staff on the floor next to his bed around 5:00 AM this morning. Resident was unresponsive, CPR was initiated, and 911 was notified. Coroner was contacted, investigated, and pronounced death at 0642 (6:42 AM) . The Emergency Medical Services (EMS) report dated [DATE] states in part: Response Time: EMS notified at 5:15 AM, the unit was enroute to the facility at 5:18 AM, arrived at the facility at 5:20 AM, was with the patient at 5:23 AM, and conducted first exam of patient at 5:24 AM. Resuscitation efforts were discontinued at 5:49 AM. The EMS Note states, in part: EMS responded immediately to a 911 call for an [AGE] year-old male found pulseless and not breathing by staff at 5:02 AM. Last known well time was 1:30 AM. The pt. was found in a supine position on the floor with bystander CPR in progress. CPR was continued by (Town name) Rural First Response throughout the call. There is dried blood on the patient's head appears he fell where found and hit his head. The defibrillator was placed on the pt. The rhythm was interpreted as asystole by paramedic. Possible lividity was noted. No vital signs noted. Assessment Summary, Skin Description: cold, lividity, dry. Mental status: unresponsive. Disposition: Dead at Scene.On [DATE] at 2:44 PM, Surveyor interviewed EMSC I (Emergency Medical Services Chief) and asked about the EMS report comment of possible lividity. EMSC I stated it means that it could have been lividity, but it could have been something else. CPR was active on arrival and we continued. Surveyor asked, if CPR had not already been started, would EMS have started CPR. EMSC I stated yes. R1's Death Notification Note, states, in part: Resident was found unresponsive and bleeding from the right side of his forehead, on the floor of his bedroom this morning around 5:00 AM when nursing staff went to give him his medication. Resident was last seen around 3:00 AM by CNA and he was sleeping at that time. CPR was initiated due to resident's full code status and 911 contacted. (county name) Coroner came, investigated, and pronounced death at 0642. Coroner advised that it appeared to be an accidental death related to unwitnessed fall.On [DATE] at 10:36 AM, Surveyor interviewed RN D (Registered Nurse) and asked about residents with low oxygen levels. RN D indicated that oxygen would be applied / turned up, a nebulizer treatment would be given per order, and oxygen level would be rechecked. If the resident's level was back up to 90%, the oxygen level would be lowered and the resident would be reassessed in a couple of hours to ensure their level was sufficient. Surveyor asked how staff was aware of a resident's code status. RN D stated that recently the room name plate was changed to green for a full code. RN D stated that some of the DNRs (Do Not Resuscitate) wear bracelets, otherwise the information was in the computer in the banner of the electronic health record. Surveyor asked who is able to perform CPR (cardiopulmonary resuscitation) in the facility. RN D stated that anyone who is certified can perform CPR; all of the nurses have to be certified. Surveyor asked about R1's status on [DATE]. RN D indicated that RN D had walked into R1's room about 5:10 AM and found R1 face down on the floor, parallel to the bed, with feet by the head end of bed. RN D rolled him over and R1 was limp. RN D felt R1's neck for a carotid pulse for about 5 seconds and watched R1's chest for breaths for about 5 seconds and determined R1 was pulseless and non-breathing. RN D yelled for the CNAs on the unit, and when they arrived, RN D left R1's room, took the elevator at the far end of the hall down to level 1 and found LPN E (Licensed Practical Nurse) midway up the hallway. RN D told LPN E that R1 was on the floor pulseless, and they went back up the elevator to level 2 to R1's room. RN D indicated that LPN E asked about R1's code status and RN D went into the computer to find the information. RN D noted that R1 was a full code and yelled the information to LPN E. RN D indicated that LPN E initiated compressions and told a CNA to call 911. RN D told LPN E that RN D could take over compressions. RN D indicated that LPN E then left to get an Ambu bag (artificial manual breathing unit). RN D indicated that compressions were done for about 5 minutes prior to EMS (Emergency Medical Services) arrival and on arrival, EMS took over and RN D went back to passing morning medications. RN D stated that following the event, the facility provided RN D with education on CPR and disciplined RN D for going to get LPN E.On [DATE] at 2:19 PM, Surveyor interviewed CNA S and asked if she had received any education on code status or CPR. CNA S indicated that they had received education after the incident with R1, but that was the first time receiving education that she could remember. Surveyor asked CNA S if she was aware of where the bag with emergency supplies for a code blue was located. CNA S stated no, she did not know where the emergency supplies were kept.On [DATE] at 2:03 PM, Surveyor interviewed LPN U, who reviewed the contents of the emergency supply bag with Surveyor on the 1st floor. Surveyor asked LPN U where additional emergency supplies were located, such as oxygen and suctioning. LPN U stated she wasn't 100% sure, but that she didn't believe that they did those things at the facility, that they would have to wait for EMS to arrive. Surveyor asked LPN U if she had done any code drills prior to the incident involving R1. LPN U stated she had not done any code drills.On [DATE] at 9:46 AM, Surveyor interviewed DON B (Director of Nursing) and asked who can perform CPR. DON B stated anyone that is certified. Surveyor asked when CPR is to be started. DON B stated if the resident is a full code, CPR is started as soon as they are found unresponsive. Surveyor asked how help is summoned in an emergency. DON B stated call light activation and unit cell phones carried by nurses. Surveyor asked if there is emergency equipment for use in a code. DON B stated yes, an AED (Automated External Defibrillator) and an emergency bag. DON B indicated there is oxygen in the storage room. Surveyor asked if CPR was expected to be initiated at the time that R1 was found unresponsive. DON B stated if the code status was known. DON B indicated the code status was located in the computer.On [DATE] at 10:43 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and asked who is expected to perform CPR. NHA A stated anyone who is CPR certified. Surveyor asked if any staff are required to have certification. NHA A stated no, the policy states that someone who is certified needs to be on duty. Surveyor asked how the facility ensures that a CPR certified staff member is on duty. NHA A stated when making the schedule, the scheduler looks. Surveyor asked when CPR is expected to begin. NHA A stated as soon as they realize the code status. Surveyor asked if staff is expected to know the code status. NHA A stated staff should be knowledgeable of the code status. Surveyor asked about emergency equipment. NHA A stated staff are shown the location of the equipment during orientation, and they are expected to know where it is located. Surveyor asked if there was a delay in starting CPR for R1. NHA A stated cannot confirm nor deny. Surveyor asked if RN D was expected to know R1's code status prior to leaving R1 and getting LPN E. NHA A stated yes, RN D should have known. Surveyor asked if facility would expect RN D to begin CPR when finding R1 unresponsive and pulseless. NHA A stated would expect someone who is CPR certified to start CPR upon finding the code status.On [DATE] at 10:55 AM, Surveyor interviewed SC H (Staffing Coordinator) and asked if SC H completes the nursing schedule. SC H stated yes. Surveyor asked if SC H considers CPR certification when making the schedule. SC H stated no, I don't look at that. Surveyor asked about CPR certifications at the facility. SC H stated the nurses are certified and some of the CNAs. Surveyor asked for documentation of certification for LPN K and ADON L (Assistant Director of Nursing). SC H stated ADON L did at times work PM shift but has been off work since [DATE]. LPN K was on schedule for [DATE]. No documentation of certification for LPN K or ADON L was provided. Of note, per Scheduler H she does not look at CPR certification when scheduling staff, though NHA A indicated the scheduler ensures a CPR certified staff member is always on duty. Therefore, there is no system in place to ensure there is a CPR certified staff member on duty each shift in case of an emergency. On [DATE] at 11:03 AM, Surveyor interviewed DON B and CCO J (Corporate Compliance Officer) about their mock code drills. DON B stated that they were not able to find any documentation of the previous administration doing mock drills. Surveyor asked when she started in the DON role. DON B stated she started in [DATE] as the DON. Surveyor asked DON B if there had been any mock code drills from [DATE] to the incident with R1 on [DATE]. DON B stated there had not been any mock code drills since she had been the DON. CCO J indicated that they are conducting mock code drills routinely now, and that they did one on [DATE], one on [DATE], and one today ([DATE]).Surveyor reviewed the Mock Code Evaluation Checklist provided by the facility and noted that CNA/CMA V had indicated on her evaluation form, no oxygen tank in the building.On [DATE] at 2:04 PM, Surveyor interviewed CCO J (Corporate Compliance Officer) and asked if when completing the facility PIP (Performance Improvement Plan), if the facility found there was a delay in treatment / delay in starting CPR for R1. CCO J stated yes, we did.On [DATE] at 4:33 PM, Surveyor interviewed DON B and EVS T (Environmental Services). Surveyor asked DON B about the Mock Code Evaluation Checklists that were provided to Surveyor, noting that 5 of them had the date of survey ([DATE]) but were only signed by one participant. Surveyor asked DON B if all the things indicated on the mock code checklist had included a return demonstration to ensure skills competency. DON B stated those were skills evaluations, that they had discussed all the items on the list and answered questions, but there had been no return demonstration. Surveyor asked DON B about CNA/CMA V's checklist form that indicated no oxygen tank in the building. DON B stated they have oxygen concentrators. Surveyor asked DON B what oxygen source had been used in R1's incident. DON B stated R1 had an oxygen concentrator. Surveyor asked DON B if an oxygen concentrator could be used with an Ambu bag. DON B stated she would have to get back to Surveyor on that. EVS T confirmed they did not have any oxygen cylinders in the building but they had them at the HR (Human Resources) building and he could get one.On [DATE] at 4:34 PM, Surveyor interviewed RN M and asked about training on codes. RN M stated a mock code had been completed and RN M had to check the scene, check pulse and respirations, call for help, check the code status, start compressions, call for 911 and AED/code bag, and call the DON. RN M stated the Ambu bag was used, but that in a real code there are masks for mouth to mask respirations. Surveyor asked about supplemental oxygen. RN M stated there was no discussion or demonstration of use of oxygen with the Ambu bag. Surveyor noted that the Mock Code Evaluation Checklist provided by the facility stated, Handheld resuscitation bag attached to oxygen source (O2 concentration minimum flow rate of 10 to 12 L/min). A review of the oxygen concentrators used by the facility indicated a maximum flow rate of 5L/min.Of note, the oxygen concentrators used by the facility would not provide a high enough flow rate to be used with an Ambu bag in an emergency situation. The facility did not have any oxygen cylinders in the building that have the capacity to go to 10 to 12L/min. On [DATE] at 5:03 PM, EVS T brought an oxygen cylinder to Surveyor and indicated he would be keeping it at the facility to be used in emergency situations.The failure to provide life saving measures immediately to a resident who wished to be provided with CPR, the failure to ensure that a CPR certified staff member was in the building at all times, and the failure to ensure all staff were aware of where lifesaving equipment was located and able to demonstrate competency of basic lifesaving equipment in a code blue situation, led to serious harm for R1 which created a finding of Immediate Jeopardy. The facility removed the jeopardy on [DATE], when it completed the following: Staff across all departments to receive education on the location of suction machine; date initiated [DATE], percentage completed: 55% Staff across all departments to receive education on location of crash cart, date initiated [DATE], percentage completed: 1% Staff across all departments to receive education on the CPR policy and Communication of Code Status policy which includes, but is not limited to, the expectation that CPR is to be conducted immediately upon discovery of a resident in cardiac arrest who is full code, CPR staff will be available at all times, checking code status utilizing new color-coded system; date initiated [DATE], percentage completed: 56% Pleasant View Nurses will complete a competency for initiating CPR per current standards of practice which includes, but is not limited to, checking code status, grabbing the emergency cart, calling 911, conducting chest compressions, utilizing the AED machine and Ambu bag, and conducting compressions until EMS arrive; date imitated [DATE], percentage completed: 45% All IDT staff received education on updated system to ensure CPR certified staff are available at all times. This system entails the scheduler to have access to a list of individuals who are CPR certified and, while creating schedules, accessing the list and ensuring everyone listed is CPR certified. Additionally, the facility has ensured every working nurse has their CPR certification ; date initiated [DATE], percentage completed: 100% Nurses who did not have an active CPR on record with the facility received education that they would be unable to return to work without an active CPR certification, ensuring all nurses are certified; date initiated [DATE], percentage complete: 100%. On [DATE], facility implemented a new color-coded system which ensured the code status of each resident was communicated to staff in an expedited manner. This entails each resident's nameplate displaying either a red (DNR) or green (Full-code) color. Additionally, assistive devices (if applicable) also have tags with the associated colors. Code status is still located under Special Instructions in the facility's EMAR for reference. On [DATE], system was updated to ensure CPR staff are available at all times and education provided. On [DATE], crash carts equipped with oxygen tanks and additional items potentially needed in an emergency were established on both the first and second floors. On [DATE], the facility implemented an assigned individual to frequently check the crash carts to confirm adequate supplies available and functionality of equipment. On [DATE], the facility implemented regular Code Blue drills with staff across all three shifts. On [DATE], CPR and CPR Communication Policies were reviewed and updated as needed to ensure appropriateness. On [DATE], the CPR and CPR Communication Policies were uploaded to the agency portal, prohibiting agency staff from working at the facility unless the policies are signed by the agency staff member. The Medical Director was updated about the incident on [DATE] DON and/or designee will complete audits daily x 2 weeks, weekly x 5 weeks and monthly x 3 months confirming that new staff have reviewed / signed off on the CPR and Communication of Code Status policies and that all Nurses have completed a competency training prior to their first shift of work. Code blue drills across all three shifts will occur weekly x5 weeks. A performance improvement plan was created on [DATE] and brought to the QAPI committee for review. As part of that performance improvement plan, audits were being conducted to ensure staff were knowledgeable regarding the color-coded system that was implemented and that the color coded system was effectively implemented. Those audits will continue on a weekly basis x 5 weeks. On [DATE], an audit was completed of all residents in-house verifying code status was correct in the medical record. All results of audits will be submitted to QAPI for review and determination of substantial compliance.

Based on interview and record review, the facility did not complete a performance review of every nurse aide at least once every 12 months for 5 of 5 Certified Nursing Assistants (CNAs) reviewed.CNA F did not have an annual performance evaluation completed timely. CNA W did not have an annual performance evaluation completed timely. CNA X did not have an annual performance evaluation completed timely. CNA Y did not have an annual performance evaluation completed timely.CNA Z did not have an annual performance evaluation completed timely. This is evidenced by:The Facility's policy titled Performance Evaluations revised September 2020 states, in part: Policy Statement: The job performance of each employee shall be reviewed and evaluated at least annually.Example 1CNA F's hire date was 5/9/23. CNA F's previous annual performance evaluation was completed on 5/9/24. CNA F did not have an annual performance evaluation completed until 8/4/25.Example 2CNA W's hire date was 7/16/96. CNA W's previous annual performance evaluation was completed on 7/10/24. CNA W did not have an annual performance evaluation completed until 8/4/25.Example 3CNA X's hire date was 12/27/21. CNA X's previous annual performance evaluation was completed on 2/26/24. CNA X did not have an annual performance evaluation completed until 8/4/25.Example 4CNA Y's hire date was 2/9/23. CNA Y's previous annual performance evaluation was completed on 3/11/24. CNA Y did not have an annual performance evaluation completed until 8/4/25.Example 5CNA Z's hire date was 4/1/24. CNA Z did not have an annual performance evaluation completed until 8/4/25.On 8/4/25, Surveyor requested and reviewed annual performance evaluations for CNA F, CNA W, CNA X, CNA Y, and CNA Z. Surveyor noted that all the performance evaluations were completed on that day.On 8/4/25 at 2:20 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how often annual performance evaluations should be completed, DON B stated every 12 months. Surveyor stated that after reviewing the evaluations provided, Surveyor noted that they all were completed on this day, DON B stated they were all completed today. Surveyor asked DON B if the evaluations were completed before or after Surveyors entered the facility, DON B stated after.

Based on interview and record review the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse were reported to other officials in accordance with State law through established procedures for 1 of 3 residents (R2) reviewed for abuse/neglect. A staff member was aware of a potential allegation of abuse, and it was not immediately reported to the administrator or designee.This is evidenced by:The Facility Policy, titled, Abuse, Neglect, and Exploitation, indicates, in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.VII. Reporting/Response. A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.Review of the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, with a Report Submitted Date of 5/27/25, indicates the following:.Summary of Incident: Allegation Type: Abuse: Hitting, slapping, threats of harm, assault, humiliation.Name - Affected Person: R2.Is date and time when occurred known? YesDate occurred: 5/23/25Time occurred: 3:46PMIs occurred date and time estimated: YesDate discovered: 5/27/25Brief Summary of Incident: A staff member was in the restroom assisting a resident use [sic] the bathroom. The resident's wife was in the room as well. It was reported that the wife was yelling at him and slapped his bare bottom. The wife also grabbed his face and said they can't slap you, but I can. Staff wrote a statement and put it under the supervisors [sic] door.The supervisor didn't work until 4 days later.On 7/22/25 at 11:23 AM, Surveyors interviewed CNA C (Certified Nursing Assistant) via telephone. During the interview CNA C indicated if she has a concern for abuse she is to contact her supervisor and fill out a statement. Surveyors reviewed with CNA C her written statement, found in the self-report involving R2, provided by the facility. CNA C confirmed it was her statement, and she had written it about an hour after witnessing the above incident with R2. CNA C indicated that she had talked to her supervisor who told her to write it up and to leave it, she believes, in the social worker's office. Of note, surveyors attempted to contact the supervisor CNA C indicated in her interview without success. On 7/22/25 at 12:00 PM, Surveyors interviewed SSS N (Social Services Supervisor) about the allegation noted above involving R2. During the interview SSS N indicated that CNA C reported the incident by putting a note under the NCC's (Nursing Care Coordinator) office door. SSS N indicated she provided 1:1 training via a phone call with CNA C and reviewed the reporting policy of calling a supervisor or administrator immediately. SSS N indicated that if a supervisor is notified of an allegation by a CNA they should call the NHA (Nursing Home Administrator), DON (Director of Nursing), or herself. SSS N indicated she did not document the education provided to CNA C.On 7/22/25 at 1:25 PM, Surveyors interviewed Consultant O, who was the INHA (Interim Nursing Home Administrator) at the time of the incident with R2. Surveyors asked how the facility ensured agency staff received the abuse education after the incident with R2. Consultant O indicated the education was left by the time clock for review, however, they did not have any type of sign off sheet for staff to sign off they completed the education. Surveyors requested a list of agency staff that have worked since the incident with R2. On 7/23/25 at 9:58 AM, NHA A provided a list of agency staff that he indicated had not received the abuse education after the above incident with R2. There are 103 names on the document provided. On 7/23/25 at 8:52 AM, Surveyors interviewed NHA A who indicated he is the abuse officer for the facility, and he works with SSS N and the DON as a team on investigations. NHA A indicated that staff are to report allegations of abuse to himself, the DON, or SSS N. Surveyor asked NHA A how they ensured agency staff received the education that was provided on reporting after the incident with R2. NHA A indicated they leave the education by the time clock for them to read. Surveyor asked NHA A how they ensure that the staff read the information. NHA A indicated they check it as best they can. Surveyor asked NHA A if the facility should be ensuring that all staff have had the education prior to working their next shift. NHA A indicated, yes. NHA A indicated he was not working in the facility during the incident with R2 and requested to have Consultant O, join the interview. Consultant O joined the interview and confirmed he was the INHA during the incident with R2. Surveyors asked Consultant O if there was a concern with the way the incident with R2 was reported. Consultant O indicated, yes, it should have been reported to him and not put under a door.

Based on interviews, record review, and policy review, the facility failed to ensure 2 of 9 residents (R) sampled for review of Abuse (R1 and R2) were free from involuntary seclusion. Findings include: Review of the facility's undated Abuse, Neglect, and Exploitation Policy and Procedure, provided by the Administrator, noted Involuntary Seclusion refers to the separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will or the will of the resident's legal representative. Emergency or short term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident's needs as long as the least restrictive approach is used for the minimum amount of time. Example 1 Review of the Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed R1 was admitted [DATE] with diagnoses that included unspecified dementia with agitation and sleep disorder. Review of the quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR with an assessment reference date (ARD) of 05/06/25 revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R1 was severely cognitively impaired. The MDS indicated R1 could ambulate independently and wore a wander guard alarm daily. Review of the comprehensive care plan, provided by the Social Services Supervisor (SSS) dated 04/16/25 revealed that R1 was an elopement risk and wandered related to dementia, disorientation, wandering aimlessly, and impaired safety awareness. Interventions included to distract me from wandering by offering pleasant diversions, structured activities, food, conversation, walking and identify my pattern and purpose of wandering, provide structured activities, toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. R1 wears a wander guard. Review of the facility's investigation, provided by the Administrator, dated 03/13/25 revealed on 03/06/25 at 6:30 AM, the Maintenance Assistant (MA) observed a mechanical lift impeding an egress as the lift blocked one side of the fire door and the other side of the fire door was closed between rooms [ROOM NUMBERS]. The investigation summarized that an agency Certified Nursing Assistant (ACNA) closed one fire door and blocked the other fire door with an unlocked mechanical lift, placed for convenience to deter (R1) from going into other resident's room. The incident was identified as an intentional act of involuntary seclusion. The ACNA was removed from the facility and terminated from employment in the facility. During an interview on 05/28/25 at 2:25 PM, the MA confirmed that between 6:00 and 6:30 AM on 03/06/25, he saw one side of the fire door blocked, and the other fire door closed on the View unit. The fire doors were located between rooms [ROOM NUMBERS]. The MA said he removed the mechanical lift, opened the fire door, and immediately notified his supervisor. The MA stated, I reported it right away because that's what you do when something isn't right. On 05/29/25 at 9:40 AM, the Administrator provided all staff training records from 10/30/24, 10/31/24, and 11/07/24 for Abuse prevention training which included involuntary seclusion The Administrator stated, The staff were trained, they should have known better. Interview on 05/29/25 at 1:00 PM, the SSS confirmed that this was involuntary seclusion. Example 2 Review of the Face Sheet located in the EMR under the Profile tab identified R2 was admitted [DATE] with diagnoses that included Alzheimer's disease, and dementia with agitation. R2 died on [DATE]. Review of the annual MDS located under the MDS tab in the EMR with an ARD of 03/25/25 revealed a BIMS score of 0 out of 15 which indicated R2 was severely cognitively impaired. The MDS indicated R2 could ambulate independently and wore a wander guard alarm daily. Review of the comprehensive care plan dated 02/05/25 revealed that R2 has the potential to be physically aggressive related to dementia and poor impulse control. R2 communicates with others by striking out due to not aware how to communicate. Interventions included give me as many choices as possible about care and activities; require increased supervision by one staff member through investigation of resident-to-resident altercation that occurred on 08/12/24; if agitated please distract me with an activity such as offer me a washcloth to wipe down railings in hallways; and that my behaviors can be decreased by walking outside, doing meaningful activities such as cleaning, wiping hand railings, folding clothes, and helping staff. I feel like I work here. Review of the behavior tracking logs located under the Tasks tab in the EMR dated 01/03/25 revealed R2 was identified to have no behaviors, grabbing others, hitting others, pushing others, physically aggressive toward others, accusing of others, expressing frustration at others, screaming at others, and threatening others. Review of the facility's investigation, provided by the Administrator, dated 01/06/25, revealed On January 4th, 2025, staff contacted the Interim Administrator and informed them that Resident Assistant (RA1) was seen by two staff members putting R2 into her room and shutting the door . Review of RA1's statement, located within the facility investigation, read, During dinner, [R2] was kind of walking around and not staying in her seat. When we directed her to eat, she didn't. Throughout the night she was trying to go into other rooms, and she didn't like being redirected. Toward the end of my shift, when she got very violent with me, she picked up (staff) sweatshirt. She flipped her switch on me and started hitting me while we were in her room and picked up her water mug and tried to hit me with it. I closed the door for my safety so I wouldn't get hit and that's when [CNA2] came in and took over. [R2] tried to swing the mug .sat on her bed, I shut the door, and that's when she started yelling help. Interview on 05/27/25 at 3:20 PM, CNA2 stated, I came onto the unit after my break and saw [RA1] taking [R2] with her arm on the resident's back, to her room and shutting the door. [R2] was yelling for help so I went to her room and helped her out. I was able to calm her down and then help her to bed. Interview on 05/29/25 at 1:00 PM, the SSS stated, During her investigation of this incident, R2 was identified to have been sitting quietly at the nurses' station prior to the incident. RA1 should not have made R2 go to her room. RA1 was angry with R2 for her earlier behaviors. RA1 was terminated.

Based on interview, record review, and facility policy review, the facility failed to ensure residents were free from physical abuse for three of four (Residents (R) R2, R11, and R8) residents reviewed for physical abuse. The facility failed to put consistent interventions into place to prevent one resident (R3) from repeated physical violence towards other residents. Findings include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Instances of abuse of all residents, irrespective of any mental or physical condition . Possible indicators of abuse include, but are not limited to . physical abuse of a resident observed . The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse . Increased supervision of the alleged victim and residents . Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all required agencies . within specified timeframes . Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Facility provided documentation and resident record review revealed three incidents of resident-to-resident aggression with R3 as the assailant. On 11/12/24, R3 was reported to have struck out at R2; on 12/06/24, R3 was reported to have struck out at R11; and on 01/12/25, R3 was reported to have struck out at R8. Review of R3's electronic medical record (EMR) Profile tab revealed R3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, anxiety disorder, dementia in other diseases severe with agitation, and insomnia. Review of R3's quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 12/17/24, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated significant cognitive impairment. Further review revealed R3 wandered one to three days during the assessment period, used a walker and wheelchair for mobility, and was supervision or touching assistance when walking ten feet, fifty feet with two turns, and walking 150 feet. Review of R3's Care Plan, located in the EMR under the Care Plan tab and initiated 06/17/23, revealed R3 had the potential to be physically aggressive (hitting others) related to dementia and poor impulse control. Interventions identified prior to the incidents below were, if R3 becomes agitated (targeting with her walker or yelling at other residents, visitors, staff) assign a staff member to stay with resident and intervene before agitation escalates, guide her away from source of distress, complete frequent checks throughout the day when out of her room, and an alarm on her to notify staff when she comes out into the hallway. Example 1: R3 to R2 on 11/12/24: Review of R2's Profile tab of the EMR revealed R2 was admitted to the facility on [DATE] with diagnoses of dementia, hypertension, and major depressive disorder. Review of R2's quarterly MDS, located under the MDS tab of the EMR and with an ARD of 11/19/24, revealed a BIMS score of 00 out of 15, which indicated significant cognitive impairment. Further review revealed R2 had no behaviors, did not wander, and required substantial/maximal assistance when walking ten feet, fifty feet with two turns, and walking 150 feet. Review of a facility provided Misconduct Incident Reporting, dated 11/12/24 at 2:45 PM, revealed that residents were coming back from an event down in the club 48 for a birthday bingo bash. Five residents who were all in wheelchairs were taken up to the second floor. R3 came up also and was attempting to get through the wheelchairs in the lobby to get to her unit. She used a walker and could not get around the residents' wheelchairs. R3 walked toward R2 in the chair and could not get past her. R3 used a closed fist and firmly banged R2 on the right shoulder three times to get her to move. A Certified Nursing Assistant (CNA8) saw it occurring and was walking over to help when the hit occurred. CNA8 helped support R3 around the wheelchairs so she could get to her unit and remove her from the area and have supervision on her unit. CNA8 checked on R2 and the Registered Nurse (RN) on staff checked R2 for bruising and injury. No bruising or injury were present. Staff also checked with R2 who did not remember anything happening. CNA8, who witnessed the incident, walked over immediately to help R3 get through and take her to the unit. Review of R3's Care Plan, located in the EMR under the Care Plan tab and initiated 03/12/24, revealed R3 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to dementia and cognitive deficits. Interventions were revised on 11/19/24 after the incident between R3 and R2 to include providing one on one supervision when going to and from activities not on her unit. During an interview on 01/16/25 at 4:33 PM, CNA8 stated that the residents were returning from an activity, and R3 wandered to where R2 and other residents were, and the area was crowded. CNA8 stated that when people are in R3's way she will ram her walker or hit people on the shoulder. She stated this was common for her when she was in a mood and would hit shoulders. Example 2: R3 to R11 on 12/06/24: Review of R11's Profile tab of the EMR revealed R11 was admitted to the facility on [DATE], with a last readmittance of 11/15/24, with diagnoses of anemia, depression, atrial fibrillation, and dysphagia. Review of R11's admission MDS, located under the MDS tab of the EMR and with an ARD of 11/19/24, revealed R11 had a BIMS score of 03 out of 15, which indicated severe cognitive impairment. Further review revealed R11 required partial/moderate assistance with mobility to walk ten feet. Review of R11's Progress Note, located under the Progress Note tab in the EMR and dated 12/06/24 at 4:52 PM, indicated R11 was .involved in a resident-to-resident incident. Resident was struck by another resident on her right arm when they weren't able to get their walker around this residents (sic) wheelchair in the hallway . No apparent injuries noted at this time. Resident is able to move her right upper extremity at baseline. Resident denies any pain at this time. Resident stated she feels safe living here at this facility . Review of the facility's Physical Aggression Initiated form, dated 12/06/24, revealed, Resident [R3] was seen walking down the hallway with her FWW (four-wheel walker). Resident came up behind another resident wheelchair [R11]. Resident was unable to maneuver her walker around the other residents (sic) wheelchair . strike resident on their arm . Resident was placed on 1:1 with designated staff . Residents agitation improved after those interventions . Immediate intervention: Staff will offer toileting and check for incontinence frequently and as needed as this is a known agitation. A written statement by Life Enrichment (LE) documented, On Friday, December 6, 2024 at 9:50 AM, I was returning two residents . from the craft fair in the community room .coming down the hall and [R3] bumped her walker into [R11] and before I could get to [R3] she struck [R11] with the side of her fist. [R3] struck [R11] in the right shoulder . I checked on [R11] to see that she was ok. She stated she was. I told her I would let staff know what occurred and she said ok . [R11] appeared fine but had an upset look on her face. The report documented that the physician and family were informed. It was not reported to the state agency or investigated. It was recorded R3 was placed on 1:1 with designated staff to ensure the safety of other residents. Review of R3's Care Plan, located in the EMR under the Care Plan tab and initiated 06/17/23, revealed R3 had the potential to be physically aggressive (hitting others) related to dementia and poor impulse control. Interventions were revised on 12/06/24 after the incident between R3 and R11 to check frequently and as needed for incontinence as that is a known trigger for agitation. During an interview on 01/16/25 at 9:30 AM, the Social Services Director (SSD) stated that the incident on 12/06/24 with R3 and R11 was not abuse due to no willful intent and no concern from R11. During an additional interview at 11:00 AM, SSD stated R11 had short-term memory which was not as good as her long-term memory. She confirmed that R11 was not interviewable. She confirmed the resident-to-resident incident on 12/06/24 was witnessed by staff. During an interview on 01/16/25 at 1:40 PM, LE stated that she was coming through the double doors with two different residents and observed R11 down the hallway. She stated she observed R3 going towards R11 with her walker. She stated that R11 was in her wheelchair going to the dayroom, and R3 was going towards R11, and she observed R3 strike R11 with the back of her hand like a swipe. She stated she reported it and filled out a statement right away. LE stated she knew it needed to be reported. LE stated she figured the management was supposed to report it, and since she filled out the information, she believed they had reported. Example 3: R3 to R8 on 01/12/25: Review of R8's Profile tab of the EMR revealed R8 was admitted to the facility on [DATE] with diagnoses of anxiety, dementia, and major depressive disorder. Review of R8's quarterly MDS, located under the MDS tab of the EMR and with an ARD of 11/12/24, revealed R8 had a BIMS score of three out of 15, which indicated severe cognitive impairment. Further review revealed R8 required partial/moderate assistance with wheel 50 feet with two turns, wheel 150 feet. Review of the facility's Physical Aggression Initiated form, dated 01/12/25, revealed, Staff reported that [R3] was standing next to a resident after the resident [R8] yelled 'ow get away . The resident reported that [R3] had struck her left shoulder. Residents separated immediately following incident one to one supervision for R3 while out of her room initiated. The resident-to-resident incident of aggression between R3 and R8 was submitted to the state agency, and still within the window of investigation. Review of R3's Care Plan in the EMR under the Care Plan tab, initiated 06/17/23, revealed R3 had the potential to be physically aggressive (hitting others) related to dementia and poor impulse control. Interventions were revised on 01/13/25 after the incident between R3 and R8 to offer for the resident to sit in her chair or lay down on her bed if it seems like she is getting tired from walking. During an interview on 01/16/25 at 2:35 PM, Registered Nurse (RN) 1 said that she was familiar with R3. She stated staff were at the nurse station, getting a resident's vitals, with other residents bunched around the nurse station as well. R3 had come down the hall and the Certified Nursing Assistants had heard that's enough or ow that's enough. They turned around and they saw R8 saying that R3 had hit her in the shoulder. RN1 stated she did not see any injury during the shift. She stated she reported the incident to Quality Improvement (QI) and the QI told her that she would handle the reporting. She stated that R3 had hit other people in the past. She stated if someone was in R3's way, she might act out in the moment. During an interview on 01/16/25 at 4:33 PM, CNA8 stated R3 had hit R8 on 01/12/25. CNA8 said she was charting and observed R3 was pacing, and then she heard R8 say that was not nice. She said R3 was placed on one-to-one supervision that night and had to have someone with her all the time when she was out of her room. CNA8 said that she had not heard about any day shift problems. She stated that staff had provided her soda and pudding, and that they were trying to find her patterns. She said no one at the facility had contacted her to follow-up, but she had received reeducation on resident abuse. During an interview on 01/13/25 at 11:35 AM, the Administrator stated that the facility had been doing a lot more education on abuse lately. He said that they had restated to the staff that it was not their decision to decide if something was abuse or not. During an interview on 01/15/25 at 8:40 AM, CNA5 stated that when R3 was out of her room, if she started to wander, the staff would put the chair alarm on her resident room door. She stated that R3 pats other residents when she is trying to get around them in the hallway. She stated R3 was not verbal. CNA5 stated that the facility would only put the resident on one to one when they see the behaviors. They would not put her on one-to-one supervision until they thought she might have a behavior. She stated the facility had regular inservicing but could not recall when the most recent education on how to care for R3 was. During an interview on 01/15/25 at 8:53 AM, CNA4 stated that the facility kept the chair alarm on R3's room door so they could know if she was exiting her room because she had a tendency to walk without her walker. CNA4 stated R3 also had behaviors and could get aggressive with residents or staff. She stated she believed the chair alarm would be put on her door at night and when she was observed having behaviors. During an interview on 01/15/25 at 9:26 AM, Licensed Practical Nurse (LPN) 2 stated that the facility had an alarm on R3's door, and when she left her room, it would indicate to staff that she had left her room. LPN2 stated R3 did have behaviors, was rarely verbal, and walked up and down the halls because she used to work at this facility. LPN2 confirmed R3 could become aggressive using her walker as she bumped and hit people as she goes around them. She stated that when the alarm on her door went off, she would be on one-to-one supervision. During an interview on 01/15/25 at 10:32 AM, the Director of Nursing (DON) stated that R3 had some behaviors such as pacing in the hall, refusing care, combativeness with staff, and some resident-to-resident altercations. She stated R3 had some worsening dementia. During an interview on 01/16/25 at 12:50 PM, CNA7 stated the facility had been doing abuse training. She stated that anything could be abuse, including resident to resident or staff to resident. During a concurrent interview on 01/16/25 at 4:50 PM with the Administrator, Registered Nurse Supervisor (RNS), and SSD, it was stated that the facility had believed they had increased education and retraining to improve abuse reporting and investigating. They stated that they believed that following the resident-to-resident abuse guidance, that R3, who had dementia, was not willful in her attempt to hit out at other residents in abusive intent, which they concluded indicated they could not substantiate abuse on the 11/12/24 incident between R3 and R2. They stated that they had continued to develop revisions to her care to prevent ongoing behaviors and had seen improvement. Facility staff were aware that when other residents are in R3's way, R3 has behaviors such as R3 will ram her walker into other Residents or hit other Residents on the shoulder. There is no indication that R3's care plan was updated to include this trigger or interventions to prevent this, resulting in R3 having multiple resident to resident altercations with other residents.

Based on interviews, record review, and facility policy review, the facility failed to ensure an allegation of resident-to-resident abuse for one of four residents (R11) reviewed for abuse out of a total sample of 11 was reported to the state survey agency (SSA) within the required time frame. Findings include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse . Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all required agencies . within specified timeframes . Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of R3's electronic medical record (EMR) Profile tab revealed R3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, anxiety disorder, dementia in other diseases severe with agitation, and insomnia. Review of R3's quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 12/17/24, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated significant cognitive impairment. Further review revealed R3 wandered one to three days during the assessment period. It was recorded R3 used a walker and wheelchair for mobility and was supervision or touching assistance when walking ten feet, fifty feet with two turns, and walking 150 feet. Review of R11's EMR Profile tab, revealed R11 was admitted to the facility on [DATE], with a last readmittance of 11/15/24, with diagnoses of anemia, depression, atrial fibrillation, and dysphagia. Review of R11's admission MDS, located under the MDS tab of the EMR and with an ARD of 11/19/24, revealed R11 had a BIMS score of 03 out of 15, which indicated significant cognitive impairment. Further review revealed R11 required partial/moderate assistance with mobility to walk ten feet. Review of the facility's Physical Aggression Initiated form, dated 12/06/24, revealed, Resident [R3] was seen walking down the hallway with her FWW (four-wheel walker). Resident came up behind another resident wheelchair [R11]. Resident [R3] was unable to maneuver her walker around the other residents (sic) [R11] wheelchair . strike resident on their arm . Resident was placed on 1:1 with designated staff . Residents agitation improved after those interventions . Immediate intervention: Staff will offer toileting and check for incontinence frequently and as needed as this is a known agitation. The report documented that the physician and family were informed. It was not reported to the state agency or investigated. A written statement by Life Enrichment (LE) documented, On Friday, December 6, 2024 at 9:50 AM, I was returning two residents . from the craft fair in the community room . coming down the hall and [R3] bumped her walker into [R11] and before I could get to [R3] she struck [R11] with the side of her fist. [R3] struck [R11] in the right shoulder . I checked on [R11] to see that she was ok. She stated she was. I told her I would let staff know what occurred and she said ok . [R11] appeared fine but had an upset look on her face. The report documented that the physician and family were informed. It was not reported to the state agency or investigated. During an interview on 01/13/25 at 11:35 AM, the Administrator stated that the facility had been doing a lot more education on abuse lately. He stated that they had told the staff that it was not their decision to decide if something was abuse or not. During an interview on 01/15/25 at 3:42 PM, the Administrator stated that the allegation of resident-to-resident abuse between R3 and R11 was not reported because there was no report that R11 had pain. During an interview on 01/16/25 at 9:30 AM, the Social Services Director (SSD) stated that the incident on 12/06/24 with R3 and R11 was not abuse due to no willful intent and no concern from R11. An additional interview at 11:00 AM, SSD stated R11 had short-term memory which was not as good as her long-term memory. She confirmed that R11 was not interviewable. She confirmed the resident-to-resident incident on 12/06/24 was witnessed by staff. SSD stated that the facility wanted staff to report potential abuse with any touching, patting, or if they felt something was wrong. She stated, We have been pushing for that with staff. She stated that they did not report the incident on 12/06/24 between R3 and R11 because they did not feel there were any observable changes in R11 after the incident. During an interview on 01/16/25 at 11:40 AM, Certified Nursing Assistant (CNA) 1 stated that she reported potential allegations of abuse if anyone reports to her or if she sees anything. She stated that resident to resident confrontations could include talking, yelling, pushing, or hitting someone. CNA1 stated if she observed R3 hit anyone, she would consider it a reportable incident. During an interview on 01/16/25 at 12:50 PM, CNA 7 stated the facility had been doing abuse training. She stated that anything could be abuse, including resident to resident or staff to resident. CNA7 stated staff were to report even potential abuse of residents, including those with dementia. During an interview on 01/16/25 at 1:40 PM, LE stated that she was coming through the double doors with two different residents and observed R11 down the hallway. She stated she observed R3 going towards R11 with her walker. She stated that R11 was in her wheelchair going to the dayroom, and R3 was going towards R11. She observed R3 strike R11 with the back of her hand like a swipe. She stated she reported it and filled out a statement right away. LE stated she knew it needed to be reported. She stated she did not believe R11 was injured. LE stated she figured the management was supposed to report it, and since she filled out the information, she believed they had reported it. During an interview on 01/16/25 at 2:35 PM, Registered Nurse (RN) 1 stated that the process for reporting was to notify the Director of Nursing or the Administrator to let them know. She stated they knew to report anything that is abuse, misappropriation of property, or neglect. RN1 stated it was not her job to determine whether it was or was not abuse. She stated they report it so it can be investigated. She stated that if someone was in R3's way, it may not have rhyme or reason, but in the spur of the moment, R3 may hit out. The potential resident-to-resident abuse between R3 and R11 was not reported to the state agancy or reported within the required time frames.

Based on staff interviews, record review, and facility policy review, the facility failed to conduct a thorough investigation for an incident of potential resident-to-resident abuse for one of four residents (R11) reviewed for abuse out of eleven sampled residents. Findings include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed, . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Identifying staff responsible for the investigation .Investigation different types of alleged violations .Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extend, and cause .Providing complete and thorough documentation of the investigation .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse Review of R3's electronic medical record (EMR) Profile tab revealed R3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, anxiety disorder, dementia in other diseases severe with agitation, and insomnia. Review of R3's quarterly Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 12/17/24, revealed R3 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated significant cognitive impairment. Further review revealed R3 wandered one to three days during the assessment period, used a walker and wheelchair for mobility, and was supervision or touching assistance when walking ten feet, fifty feet with two turns, and walking 150 feet. Review of R11's Profile tab of the EMR revealed R11 was admitted to the facility on [DATE], with a last readmittance of 11/15/24, with diagnoses of anemia, depression, atrial fibrillation, and dysphagia. Review of R11's admission MDS, located under the MDS tab of the EMR and with an ARD of 11/19/24, revealed R11 had a BIMS score of 03 out of 15, which indicated severe cognitive impairment. Further review revealed R11 required partial/moderate assistance with mobility to walk ten feet. Review of the facility's Physical Aggression Initiated form, dated 12/06/24, revealed, Resident [R3] was seen walking down the hallway with her FWW (four-wheel walker). Resident came up behind another resident wheelchair [R11]. Resident was unable to maneuver her walker around the other residents (sic) wheelchair . strike resident on their arm . Resident was placed on 1:1 with designated staff . Residents agitation improved after those interventions . Immediate intervention: Staff will offer toileting and check for incontinence frequently and as needed as this is a known agitation. A written statement by Life Enrichment (LE) documented, On Friday, December 6, 2024 at 9:50 AM, I was returning two residents . from the craft fair in the community room .coming down the hall and [R3] bumped her walker into [R11] and before I could get to [R3] she struck [R11] with the side of her fist. [R3] struck [R11] in the right shoulder . I checked on [R11] to see that she was ok. She stated she was. I told her I would let staff know what occurred and she said ok . [R11] appeared fine but had an upset look on her face. It was recorded R3 was placed on 1:1 with designated staff to ensure the safety of other residents. Review of the facility's Physical Aggression Received form, dated 12/06/24, revealed, Resident [R11] was seen self-propelling in her wheelchair down the hallway when another resident came .resident was unable to get her walker around the residents (sic) wheelchair. The other resident .struck this resident with her arm on her right arm .Immediate intervention: other resident was placed on 1:1 with designated staff to ensure safety of other residents. The report documented that the physician and family were informed. Record review revealed there was an incomplete investigation of the resident-to-resident abuse incident between R3 and R11. A written witness statement from Life Enrichment (LE) was completed and placed in the report, without follow-up. There were no additional staff interviews regarding the behaviors of R3, nor if they had witnessed a similar concern. There were no witness statements from other residents or visitors as it occurred in a common hallway. Residents from the facility were not interviewed to determine if they felt safe residing on the same unit with R3, or if they had experienced similar incidents. During an interview on 01/13/25 at 11:35 AM, the Administrator stated that the facility had been doing a lot more education on abuse lately. He said that they had told the staff that it was not their decision to decide if something was abuse or not. During an interview on 01/15/25 at 10:32 AM, the Director of Nursing stated that R3 had some behaviors such as pacing in the hall, refusing care, combativeness with staff, and some resident-to-resident altercations. She stated R3 had some worsening dementia. During an interview on 01/16/25 at 2:35 PM, Registered Nurse (RN) 1 said that the process for reporting was to notify the Director of Nursing or the Administrator to let them know. She said they knew to report anything that is abuse, misappropriation of property, or neglect. RN1 said it was not her job to determine whether it was or was not abuse. She stated they report it so it can be investigated. She confirmed R3 had hit other people. She stated that if someone was in R3's way, it may not have rhyme or reason, but in the spur of the moment, may hit out. The potential resident-to-resident abuse was not thoroughly investigated.

Based on interview, record review, and facility policy review, the facility failed to contact the pharmacy to ensure medications were available for administration for two of three residents (Resident (R) 6 and R9) reviewed for medication administration out of a sample of eleven residents. Findings include: Review of the facility's undated policy titled, Pharmacy Policy and Procedure Omnicell Manual, revealed Nursing Home staff and HealthDirect Pharmacy will use the Omnicell System as an inventory, charging, and information system for the control and distribution of medications for Continuous Dosing, Emergency, and First-Dose use . All licensed staff nurses will have access privileges to controlled medications pursuant to a valid prescription order . All licensed staff nurses will have access privileges to non-controlled medications . Charge Nurses, Director of Nursing, and some Pharmacy personnel may have some of the following privileges . Refilling of non-controlled and controlled medications . Head nurses are able to create a transaction slip that assigns a visiting nurse a Temporary I.D. and Password. This temporary I.D. and password will give the visiting nurse access to the non-controlled medications in the Omnicell System for a timeframe of 1 to 5 days . The nursing home should have at least one resource nurse on each shift. The resource nurse will assist other nurses and will act as the liaison with the Omnicell customer support team . Example 1 Review of R6's Admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE]. R6 was admitted with diagnoses including chronic obstructive pulmonary disease, abdominal aortic aneurysm without rupture, anxiety, and cerebral infarction. Review of R6's Care Plan, located in the EMR under the Care Plan tab and initiated 04/24/23, revealed R6 had emphysema/chronic obstructive pulmonary disease related to smoking. Interventions included giving aerosol or bronchodilators as ordered and nursing staff will consider awakening the resident in the morning to administer inhalers as ordered, in order to attempt being proactive with his feelings of shortness of breath. Review of R6's quarterly Minimum Data Set (MDS), located in the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 11/05/24, revealed R6 had a Brief Interview for Mental Status (BIMS) assessment with a score of six out of 15, which indicated significant cognitive impairment. It was documented R6 received hospice services. Review of R6's EMR under the Orders tab revealed an order, dated 12/31/23, for Combivent Respimat Inhalation Aerosol Solution 20-100 MCG/ACT (microgram) one puff inhale orally four times a day for SOB [shortness of breath]/Wheeze related to Chronic Obstructive Pulmonary Disease. The Combivent was to be administered at 7:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. Review of R6's Medication Administration Record (MAR), located under the Orders tab of the EMR and dated January 2025, revealed no documentation to show the Combivent Respimat Inhalation Aerosol Solution 20-100 MCG/ACT was administered on 01/05/25 at 4:00 PM and 8:00 PM, on 01/06/25 at 7:00 AM, 12:00 PM, and 4:00 PM, and on 01/07/25 at 4:00 PM. Review of R6's Progress Notes tab of the EMR revealed the following documentation related to the Combivent Respimat Inhalation Solution: 01/05/25 at 4:12 PM - no inhaler found. 01/01/25 at 8:26 PM - Med (medication) not available. 01/06/25 at 8:47 AM - resident is out of his Combivent inhaler .was reordered on 12/30/24 and .reordered it today .so he missed yesterday doses and this morning dose. 01/06/25 at 11:38 AM - no supply here pharmacy called and they will be sending it today. 01/06/25 at 4:39 PM - not available. 01/07/25 at 6:30 PM - no med (medicine) available. Review of R6's clinical record revealed an identified concern in an email correspondence on 01/13/25 by R6's power of attorney (POA), with documentation that R6's Combivent inhaler Rx (prescription) was not available. He has missed 5 dosages, 1/5-1/6 and didn't get the RX [prescription] till 1/7. Example 2 Review of R9's Admission Record, found in the Profile tab of the electronic medical record (EMR), revealed she was admitted to the facility on [DATE]. R9 was admitted with diagnoses including essential hypertension, depression, osteoporosis/polymyalgia rheumatica, gastroesophageal reflux disease, heart failure, and anxiety. Review of R9's Care Plan in the EMR under the Care Plan tab and initiated 12/26/24, revealed R9 had osteoporosis/polymyalgia rheumatica. Interventions included administering analgesia as per orders, anticipating her need for pain relief and responding immediately to any complaint of pain. It was also recorded that R9 had anxiety and took sertraline. Interventions included administering medications as ordered. Review of R9's Care Plan in the EMR under the Care Plan tab, initiated 12/26/24, revealed R9 had anxiety and took Sertraline. Interventions included administering medications as ordered. Review of R9's admission (MDS, located under the MDS tab in the EMR and with an Assessment Reference Date (ARD) of 12/31/24, revealed R9 had a BIMS score of 15 out of 15, which indicated no cognitive impairment. It was documented that R9 received an antidepressant, anticoagulant, and diuretics. a Review of R9's EMR under the Orders tab revealed an order dated 12/26/24 for Famotidine Oral tablet 20 MG (milligram), give one table by mouth at bedtime related to gastroesophageal reflux disease without esophagitis. The famotidine was to be administered daily at 8:00 PM. Review of R9's MAR, dated 01/2025 and located under the Orders tab of the EMR, revealed R9 was not administered the famotidine 01/03/25, 01/05/25, and 01/06/25. Review of R9's Progress Notes tab of the EMR revealed the following documentation related to the famotidine: 12/30/24 at 9:02 PM - n/a (not available). 01/03/25 at 8:14 PM - on order. 01/05/25 at 8:26 PM - medication not available. On order. 01/06/25 at 9:10 PM - medication not available; waiting for delivery from pharmacy. Review of R9's EMR under the Orders tab revealed an order dated 12/27/24 for Prednisone Oral Tablet 2.5 MG, give one tablet by mouth one time a day related to polymyalgia rheumatica. The Prednisone was to be administered daily at 8:00 AM. Review of R9's MAR, dated 01/2025 and located under the Orders tab of the EMR, revealed no documentation that R9's prednisone was administered on 01/01/25 and 01/02/25. Review of R9's Progress Notes tab of the EMR revealed the following documentation related to the prednisone: 01/01/25 at 9:08 AM - on order. 01/02/25 at 8:59 AM - on order. Review of R9's EMR under the Orders tab revealed an order dated 12/27/24 for Sertraline HCl Oral Tablet 50 MG, give one tablet by mouth one time a day related to generalized anxiety disorder. The sertraline was to be administered daily at 8:00 AM. Review of R9's MAR, dated 01/2025 and located under the Orders tab of the EMR, revealed no documentation that R9's sertraline was administered on 01/01/25 and 01/02/25. Review of R9's Progress Notes tab of the EMR revealed the following documentation related to the sertraline: 01/01/25 at 9:08 AM - on order. 01/02/25 at 9:00 AM - on order. Facility provided documentation of the Omnicell Medication contents revealed that famotidine 20 mg, prednisone 1 mg, 10 mg, and 20 mg, and sertraline 50 mg were all available in the onsite system. During an interview on 01/15/25 at 9:26 AM, Licensed Practical Nurse (LPN) 2 stated that she was an agency nurse but worked at the facility as needed. LPN2 stated she could reorder medications in the EMR, and she could fax if she needed a new prescription. She stated she did not know if the facility had given her access to the Omnicell system, but if she knew she could, she would go to management to get permission to use it. She stated as an agency nurse, she was not given permission to access the medications in the Omnicell. During an interview on 01/15/25 at 9:33 AM, Registered Nurse (RN) 3 stated she was an agency nurse. She stated that if a resident needed medication that was not available, she would call the pharmacy or contact them through the EMR. She stated she was not aware of an Omnicell system at the facility to access medications onsite. During an interview on 01/15/25 at 10:17 AM, LPN1 stated she was not aware that the facility had an Omnicell system to access medications. She stated that she would contact the pharmacy if a medication was not found. During a concurrent interview on 01/15/25 at 10:24 AM with the Pharmacist and the Director of Nursing, the Director of Nursing stated that the facility had an Omnicell system, or nurses could call pharmacy for an order, or use the EMR to order medications. She confirmed the facility nurses had access to the Omnicell and that the regular nurses had access to. She stated that they were looking to get more frequent agency staff access to it as well. The Pharmacist stated the Omnicell was stocked very robustly with medications. The DON stated that if the facility identified that a medication had been coded as not given to a resident, they should contact the pharmacy, contact a local pharmacy, or look into getting a different medication. She stated that they would alert the provider and pharmacy if the resident had gone multiple days without medication. She stated that for new admit residents, the medications would be faxed to the pharmacy and should arrive by night shift. She stated if a medication was pertinent or needed to be given immediately, after reviewing the medication reconciliation, they look to see if it was in their contingency supply to provide them. The DON confirmed she would not expect residents to go multiple days without medications. She also confirmed that R6's Combivent was reordered but was missed by pharmacy and sent at a later date. She stated the resident should not have missed his Combivent. During an interview on 01/15/25 at 11:33 AM, Quality Improvement (QI) and the Administrator stated that they had identified that medication orders were not placed correctly into the system for R6 to get his Combivent and that he did miss a number of doses of it. The Administrator stated that they had developed a performance improvement plan (PIP) to work on getting medications in from pharmacy, as staff have realized they are at the end of the pharmacy's run. During an interview on 01/16/25 at 10:28 AM, R9 stated that when she was admitted to the facility there had been a real problem in getting her medication in from pharmacy. She said she was not aware of why there was a delay in providing the medicine. During an interview on 01/16/25 at 4:30 PM, RN2 stated that she was an agency nurse. She stated that she had to reorder medications through the EMR but was told by another nurse that the system did not work very well. She stated that the other nurse told her that she faxed the reorders to the pharmacy, but it did not seem to work as well as it should. RN2 stated the agency nurses were told that they did not get access to the Omnicell and that none of the staff nurses had volunteered to help them get access to the system. RN2 stated that if a resident's medication was not available, some nurses did not have time to hunt down a way to get the orders filled. She stated that was why she believed there are a lot of progress notes indicating the medication was on order and not available. RN2 stated access to the Omnicell would help considerably. During a concurrent interview on 01/16/25 at 4:50 PM with the Administrator, Registered Nurse Supervisor (RNS), and Social Services Director (SSD), RNS confirmed that the facility believed it was possible the nurses were not hitting receive on the EMR when requesting medications from the pharmacy so that medications would be processed and submitted. RNS also stated that some of the agency nurses had come to her the other day to ask for help getting into the Omnicell. It was confirmed in the interview that they did not want residents to go without medications. The Administrator stated he wanted to see the attempts to get the medications documented and they have put notes on the medication carts to let nurses know if they need medications from the Omnicell, they can get help accessing it.

Based on observation, interview, and record review the facility failed to ensure 3 of 3 residents (R1, R2, and R3) were free from involuntary seclusion. The facility moved R1, R2, and R3 from the unit they resided on and placed them on a different unit within the facility. Facility staff erected a wall and placed R1, R2, and R3 behind this wall. R1, R2, and R3's families were not aware R1, R2, and R3 were being secured behind a wall isolating the residents from others in the facility. Using the reasonable person concept a resident would be fearful, anxious and feel dehumanized, when not afforded the individuality, compassion and civility as others who reside at the facility. As the Psychosocial Outcome Severity Guide, located in the Nursing Home Survey Resources Folder, describes, to apply the reasonable person concept, the survey team should determine the severity of the psychosocial outcome or potential outcome the deficiency may have had on a reasonable person in the resident's position (i.e., what degree of actual or potential harm would one expect a reasonable person in the resident's similar situation to suffer as a result of the noncompliance). Generally, when applying the reasonable person concept, the survey team should consider the following as it determines the outcome to the resident, which include, but is not limited to: The resident may consider the facility to be their home, where there is an expectation that he/she is safe, has privacy, and will be treated with respect and dignity. The resident trusts and relies on facility staff to meet his/her needs. The resident may be frail and vulnerable. This is evidenced by: The State Operations Manual states in part: Involuntary seclusion is defined as separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will or the will of the resident representative. NOTE: During a situation in which a resident's behavior has escalated and immediate interventions are required for the safety of the resident, staff and/or other residents, the facility must immediately consult with the resident's physician about the behavioral symptoms and the resident's designated representative; and provide necessary supervision of the resident to ensure that the resident and other residents are protected. Involuntary seclusion may take many forms, including but not limited to the confinement, restriction, or isolation of a resident. Involuntary seclusion may be a result of staff convenience, a display of power from the caregiver over the resident or may be used to discipline a resident for wandering, yelling, repeatedly requesting care or services, using the call light, disrupting a program or activity, or refusing to allow care or services such as showering or bathing to occur. Involuntary seclusion includes, but is not limited to, the following: A resident displays disruptive behaviors, such as yelling, screaming, distracting others (such as standing and obstructing others viewing abilities for the TV or programs) and staff remove and seclude the resident in a separate location such as in an office area or his/her room, leaving and closing the door and without providing interventions to address the behavioral symptoms. In an attempt to isolate a resident to prevent him/her from leaving an area, the resident(s) is involuntarily confined to an area by staff placing furniture, carts, chairs in front of doorways or areas of egress. Staff place a resident in a darkened room, office, or area secluded from other staff and residents for convenience or as punishment. A resident placed in a secured area of the facility but does not meet the criteria for the unit and is not provided with access codes or other information for independent egress. Considerations Involving Secured/Locked Areas If a resident resides in a secured/locked area that restricts a resident's movement throughout the facility, the facility must ensure that the resident is free from involuntary seclusion. The facility involves the resident/representative in care planning, including the decision for placement in a secured/locked area and the development of interventions based upon the resident's comprehensive assessment and needs; and the facility provides immediate access and visitation by family, resident representative, or other individuals, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent. It is expected that each resident's record would include: documentation of the clinical criteria met for placement in the secured/locked area by the resident's physician along with information provided by members of the interdisciplinary team; documentation that reflects the resident/representative's involvement in the decision for placement in the secured/locked area; documentation that reflects whether placement in the secured/locked area is the least restrictive approach that is reasonable to protect the resident and assure his/her health and safety; documentation by the interdisciplinary team of the impact and/or reaction of the resident, if any, regarding placement on the unit; and ongoing documentation of the review and revision of the resident's care plan as necessary, including whether he/she continues to meet the criteria for remaining in the secured/locked area, and if the interventions continue to meet the needs of the resident. NOTE: A resident who chooses to live in the secured/locked unit (e.g., the spouse of a resident who resides in the area), and does not meet the criteria for placement, must have access to the method of opening doors independently. The chosen method for opening doors (e.g., distribution of access code information) is not specified by the Center of Medicare and Medicaid Services. The facility posted a sign dated 9/30/24 for all staff, the sign states in part; In response to the last survey visit on 9/16/24. The only way to guarantee other residents are safe; we have issued a 30-day notice to (R1) and (R2). (R1), (R2) and (R3) will be housed in the Way unit. Not ideal but for us to have a chance of being cleared, this needs to happen. The Division of Quality Assurance is in receipt of photos of a large blue wall that appears affixed to the cement wall. Additionally, DQA received photos of yellow accordion floor signs and an armed chair that are placed in front of the fire doors in what appears an effort to block exit through these doors. On 10/8/24 at 6:00 PM, Surveyor entered the lobby area on the main floor of the facility. Surveyor walked down the hall and immediately observed a large blue paneled wall erected across the hallway on the Way unit. The wall was approximately 6 feet high and secured to the cement wall with a metal bracket. The hallway where the wall was erected was very gloomy and dark. Surveyor could hear a staff member speaking to a resident but could not see a way to open the wall or get onto the Way unit. Surveyor walked down the hall and found a nurse who called the nurse manager. On 10/8/24 at 6:10 PM, Surveyor interviewed NM M (Nurse Manager) regarding the wall. Surveyor asked NM M what the purpose of the wall was. NM M stated 3 residents were moved to the unit and the wall was erected to keep the residents on the hall so they would not wander off the unit. Surveyor asked NM M how families get behind the wall to see their loved ones. NM M stated families would let someone know they are coming or are here and staff can assist them to get onto the unit. Surveyor asked NM M what would staff do in the event of an emergency or fire. NM M stated someone would be at the front of the building and let EMS (Emergency Medical Services) or fire in to the building and behind the wall. Staff can open the wall and residents can walk off the unit. Surveyor asked NM M if she was aware if families were upset by this move. NM M stated she had not heard families were upset. On 10/8/24 at 6:30 PM, Surveyor met DON B (Director of Nursing) and asked how Surveyor could get onto the Way unit. DON B took Surveyor onto the elevator and went up to the DSU (Dementia Stabilization Unit), Surveyor and DON walked through the DSU and down the stairs and onto the Way unit. Surveyor asked DON B how family members get to the Way unit. DON B stated family members can take the same route we just did. It should be noted two of the residents on the Way unit have elderly spouses who visit. On 10/8/24 at 6:33 PM, Surveyor entered the Way unit with DON B. The Way unit had one CNA, CNA N (Certifed Nursing Assistant) on the unit. R3 was up in her wheel chair and R1 and R2 were in bed. Surveyor noted the fire doors at the end of the hall were open and the blue wall was just beyond the fire doors. Surveyor noticed a tab alarm affixed to the door jamb of R1's door with a string attached to the magnet affixed to the alarm box. Surveyor asked DON B what the tab alarm was for. DON B stated we can pull R1's door shut and attach the string to the door and then leave the door slightly ajar. If R1 gets up and opens the door the alarm will sound, and we know R1 is up. It should be noted the string was not attached to the door and R1 was in her bed at the time of this observation. DON B walked down the hall with Surveyor and showed Surveyor if you close the fire doors there was a box affixed to the fire doors and a string that attached to the fire door handles. If the string is attached to the handles and the door is opened a call alarm goes off at the kiosk at the end of the hall indicating the fire doors have been opened. Surveyor asked CNA N if she was aware if families were upset by this move. CNA N stated she had not heard families were upset. On 10/8/24 at 6:35 PM, Surveyor interviewed CNA N (Certified Nursing Assistant) regarding the residents on the Way unit. Surveyor asked CNA N if she knew why the residents were on the Way unit behind the wall. CNA N stated the 3 residents R1, R2, and R3 had been involved in several resident-to-resident incidents and they were moved to the Way unit for their safety and other residents safety. Surveyor asked CNA N if the residents are able to go off the unit for activities. CNA N stated there is a few things here we can do with the residents. CNA N pointed to a book case with coloring books, books, a radio and stated there is TV. Surveyor asked how the residents families get on to the unit to visit. CNA N stated families do not have to do the stairs there is a way to open the wall up from the middle to let staff and visitors on and off the unit. Surveyor asked CNA N what she would do in the event of an emergency. CNA N stated she has a phone and can call for assistance. Surveyor asked what you would do in the event of a fire or an emergency requiring EMS. CNA N stated she can open the wall and let EMS or fire onto the unit, or she can take the residents off the unit. Example 1 R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Seizure disorder, Depression, and Insomnia. R1's Quarterly MDS (Minimum Data Set) dated 9/18/24 indicates R1 has a BIMS (Brief Interview of Mental Status) of 0 out of 15, indicating R1 is severely cognitively impaired Section E indicates that out of the last 7 days R1 has behavioral symptoms toward others 1-3 days, Verbal Symptoms toward others 1-3 days, behavioral symptoms not directed toward other 1-3 days, rejection of care 1-3 days and wanders 1-3 days. Impact to Resident and other residents is blank. Section GG indicates R1 is dependent for toileting hygiene, showers, upper and lower body dressing, and personal hygiene. R1's care plan states in part; Focus: Daily preferences of care. Goal: I will be satisfied with care provided. Interventions: Interventions it is very important to me to have my husband and my daughter involved in care and discussions. R1's care plan states in part; Focus: I am dependent on staff for meeting my emotional, intellectual, physical, and social needs related to dementia and cognitive deficits. Goal: I will maintain involvement in cognitive stimulation, social activities as desired. Interventions: I need assistance with ADLs (activities of daily living) as required during the activity. I need escort to activity functions. I prefer activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as music, crafts, and baking. Introduce me to residents with similar background, interests, and encourage/facilitate interaction. Invite me to scheduled activities. R1's care plan states in part; Focus: I have the potential to be physically aggressive (hitting other) related to dementia, poor impulse control. Goal: I will not harm self or others. Interventions: Ask resident what can be done to help her feel better. Make sure resident feels reassured and in a safe environment where she can feel comfortable in her surroundings. Allow 15 minutes for resident to calm herself, rest in bed if tired, or all ow time for as needed work. Provide calm environment. I require frequent checks throughout the day and an alarm on my door to notify staff when I come out into the hallway. Monitor each shift and as needed, document observed behavior and attempted interventions in behavior log. Monitor/document/report as needed any signs and symptoms of me posing danger to self and others, If I am posing a threat to other residents have a staff member assigned to monitor me or spend time with me. Resident has shown increased confusion and wandering into peers rooms, particularly after experiencing a sleepless night, absence seizure, pain, that she is unable to express, or concerns with constipation, if increased restlessness and wandering consider providing reassurance, acknowledge feelings, ensure safety of peers if wandering into other rooms or off unit. Staff should be calm and polite in redirectable attempt. If resident is not responding, use positive excitement to have resident follow you to a safe area rather than trying to physically redirect resident. Physically redirecting resident when she is in heightened state may exacerbate defensive response and lead to resident being more resistant to go in your direction, or even strike out. When I become agitated assign a staff member to staff with resident. R1's care plan states in part; Focus: I need placement in dementia specific facility to meet my needs of safety. Goal: My discharge goals are dementia specific facility. Interventions: Social Services to coordinate discharge to dementia specific placement. Support to be provided to family regarding changes occurring. R1's progress notes state the following: 10/2/2024 15:47 (3:47 PM) Facility initiated room change form and facility-initiated discharge notices were emailed to (Ombudsman Name) this date. On 9/27/24 the facility issued a document to R1's husband that states in part: Facility-Initiated Room Transfer. Resident Name: (R1). Date of written notice given or mailed: 9/27/24 (per phone). Resident Representative Name: FM S (Family Member) name, R1's AHCPOA (Activated Health Care Power of Attorney). This is to notify you of an upcoming move within the facility to another room with the facility. You will be moved from Room Number (room number) on Lane Unit to Room Number (Room Number) on the Way unit. The expected move date is 9/30/24. Family friends are welcome to assist with the move, but staff are available to move belongings as needed. The purpose of the move: Smaller unit to control behaviors affecting others and allow wandering. (Facility Name) understand that moving rooms can be a big change for some individuals, and every care is taken in making the right decision for all of our residents. However, you do have the right to contest this decision and contact your local Ombudsman about this move. The Ombudsman covering this area is: The Ombudsman for [NAME] County is: (Ombudsman C's Name) Email: (Email address) and Phone (Phone Number). On 10/8/24 at 8:12 PM Surveyor interviewed FM J (Family Member) regarding R1's FIRC (Facility-Initiated Room Change). FM J stated on Friday 9/27/24, the facility contacted (R1's) AHCPOA FM S regarding the FIRC. FM S was told that R1 and two other residents would be moving to a different part of the facility. FM J stated FM S was not given and explanation for the reason for the transfer and the family did not know why this was occurring. Surveyor asked FM J if the family was aware R1 was going to be housed behind a wall and placed in a location without contact with others in the facility. FM J stated the facility did not share there would be a wall erected and (R1) would be housed behind the wall. FM J stated her, and her sister came to visit on Saturday 9/28/24, and they were absolutely mortified this was a huge shock to see the location (R1) was being housed. FM J stated it was dark back on the hall and they had no idea a large wall was up and (R1) was being kept behind a wall. FM J stated my sister, and I just could not believe what we were seeing. Surveyor asked how you and your sister got back onto the Way unit. FM J stated she was aware of how these partitions work and she kept looking for a place to pull the partition apart FM J stated she finally found a place and opened it up and her and her sister walked back on to the Way unit. FM J stated (R1) seemed very withdrawn she was not herself. FM J stated R1 was on her bed looking up at the ceiling and just staring this was very unlike her she is almost always up and out of her room. FM J stated we were just so shocked when we saw this unit and were very concerned about the lack of interaction and activity stimulation. It was all just so shocking I really don't have words for how we felt about the situation except completely saddened and shocked. On 10/9/24 at 8:15 AM Surveyor observed R1 to be in her room lying on her bed and looking up at the ceiling. R1 received her meal about 8:25 AM and was lying in bed and would lean over and fed herself bites at a time. On 10/9/24 at 8:40 AM Surveyor observed R1 up in the hall ambulating with her walker. Example 2 R2 was admitted on [DATE] with diagnosis that include Alzheimer's, Dementia, muscle weakness and unsteadiness on feet. R2's Quarterly MDS (Minimum Data Set) dated 10/1/24 indicates R2 has a BIMS (Brief Interview of Mental Status) of 0 out of 15, indicating R2 is severely cognitively impaired. Section B indicates R2 hears adequately, has clear speech, usually makes self-understood, and usually understands others. Section E indicates that R2 has not had rejection of cares, physical, verbal, or other behavioral symptoms, or wandering in the last 7 days. Impact to Resident and other residents is blank. Section GG indicates R2 needs supervision or touching assistance with toileting hygiene, showers, lower body dressing and personal hygiene. R2 is independent with sitting to lying, lying to sitting, sitting to standing and transferring from chair to bed or bed to chair, toileting, and walking. On 9/27/24 the facility issued a document to R2's responsible party that states in part: Facility-Initiated Room Transfer. Resident Name: (R2). Date of written notice given or mailed: 9/27/24 (per phone). Resident Representative Name: FM K (Family Member) name, R2's Guardian. This is to notify you of an upcoming move within the facility to another room with the facility. You will be moved from Room Number (room number) on Lane Unit to Room Number (Room Number) on the Way unit. On 10/9/24 at 8:55 AM Surveyor interviewed FM K regarding R2's FIRC (Facility-Initiated Room Change). FM K stated she received a call on Friday 9/27/24 at approximately 3:30. FM K stated she was on vacation up north when she received the call from SW R (Social Worker). FM K stated she was told the facility was moving (R2) to see how that would work to prevent incidents. FM K stated I thought this was awful (R2) has severe dementia and moving her would likely make things worse not better. FM K stated she was also told on Friday if this did not work the facility would be requesting the family look at moving (R2) elsewhere. Surveyor asked FM K if she was aware R2 would be housed behind a wall. FM K stated I was not aware and was beside myself when I saw the wall, it's just terrible. Surveyor asked FM K how you were able to get back on the unit. FM K stated a staff member helped her onto the unit and now she knows how to separate the wall and does it herself. FM K stated there is not enough staff back on the unit, little stimulation and it is terrible how they are back on this unit alone. FM K stated she came to the facility on Monday morning after the move and R2 was beside herself, very disoriented to her new surroundings. FM K stated we were told that (R2) needed to move as the facility was unhappy about the number of incidents (R2) was involved in. The facility stated they were providing 1:1 staffing to prevent the incidents, but I never saw that. We were told the facility was receiving too many citations. This is all just very upsetting and wrong. Example 3 R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, chronic pain, delusional disorders, major depression, anxiety, and adjustment disorder. R3's Quarterly MDS (Minimum Data Set) dated 9/10/24 indicates R3 has a BIMS (Brief Interview of Mental Status) of 0 out of 15, indicating R3 is severely cognitively impaired Section E indicates that out of the last 7 days 1-3 days, behavioral symptoms not directed toward other. Section GG indicates R3 is supervision/maximum assistance for toileting hygiene, showers, dressing, and personal hygiene. R3's care plan states in part; Focus: daily Preferences of Activities. Goal: I will be satisfied with activities provided. Inteventions: It is important to me, but I am unable to do my favorite activities due to Alzheimer's. It is important to me, but I am unable to go outside to get fresh air when the weather is good due to Alzheimer's. R3's care plan states in part; Focus: I am dependent on staff for meeting my emotional, intellectual, physical, and social needs related to advanced Alzheimer's. Goal: I will attend/ participate in activities as able. Interventions: I need escort to activity functions. I prefer activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities. Invite me to scheduled activities. My preferred activities are 1:1, sitting gin the common area with groups of people, listening to music, walking with a staff member, rolling a yarn ball, caring for baby doll. R3's care plan states in part; Focus: I have the potential to be physically aggressive (hitting, pinching, grabbing, running into staff with my wheelchair) related to dementia, history or harm to others, poor impulse control. Goal: I will not harm others. Interventions: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Assess contributing sensory deficits. Assess and anticipate my needs. Complete frequent checks. Modify environment, adjust room temperature to comfortable level, reduce noise, dim lights, place familiar objects in room keep door closed. Monitor and document me posing harm to self or others. When starts grabbing for others' we will provide something for her to do with her hands i.e. hold our hands, stuffed animal, baby. When I appear distressed ex. self-propelling in the hallways steadily or reaching out to others, the floor nurse will assign a staff member to stay with her and keep others out of the way. When I become agitated intervene before agitation escalates guide me away from source of distress engage me calmly in conversation. When I have increased anxiety and agitation pleas try to redirect me to my room so I can lay down for a little while then reassess anxiety/agitation after that. On 9/27/24 the facility issued a document to R3's AHCPOA (Activated Health Care Power of Attorney) FM L (Family Member) that states in part: Facility-Initiated Room Transfer. Resident Name: (R3). Date of written notice given or mailed: 9/27/24 (per phone). Resident Representative Name: FM L (name). This is to notify you of an upcoming move within the facility to another room with the facility. You will be moved from Room Number (room number) on Lane Unit to Room Number (Room Number) on the Way unit. The expected move date is 9/30/24. On 10/9/24 at 2:30 PM Surveyor interviewed FM L regarding R3's room transfer and if she was aware the facility was placing R3 behind a wall. FM L stated the facility was upfront with her and she did not have a concern with the R3's room transfer or where R3 was being housed. On 10/9/24 at 6:30 AM Surveyor interviewed CNA P regarding her knowledge of moving R1, R2 and R3 to the Way unit. CNA P stated she was told there were safety concerns with resident-to-resident incidents and wandering. This area would have less activity, be a calmer environment and would allow R1, R2 and R3 the freedom to wander. Surveyor asked CNA P what she would do in the event of an emergency. CNA P stated she has a phone and can call for assistance. Surveyor asked what you would do in the event of a fire or an emergency requiring EMS. CNA P stated she can open the wall and let EMS or fire onto the unit, or she can take the residents off the unit. Surveyor asked CNA P if families were supportive of the move or the wall. CNA P stated she has not heard families had a concern with the move or the wall. On 10/9/45 at 6:45 AM Surveyor interviewed RA/CNA Q (Resident Assistant/Certified Nursing Assistant) regarding her knowledge of moving R1, R2 and R3 to the Way unit. RA/CNA Q stated she was told there were behavior issues on the other unit the R1, R2 and R3 resided on before the move to the Way unit. RA/CNA Q stated the thought was moving the 3 residents to this unit would allow for closer observation and hope to reduce behaviors. Surveyor asked RA/CNA Q what she would do in the event of an emergency. RA/CNA Q stated she has a phone and can call for assistance. Surveyor asked what you would do in the event of a fire or an emergency requiring EMS. RA/CNA Q stated she can open the wall and let EMS or fire onto the unit, or she can take the residents off the unit. Surveyor asked RA/CNA Q if families were supportive of the move or the wall. RA/CNA Q stated she knows that R2's husband was very upset about the entire situation, and she referred him to social services. On 10/9/24 at 8:35 AM Surveyor interviewed SW R (Social Worker) regarding the room changes for R1, R2 and R3. SW R stated she called the families on Friday 9/27/24 and told them the residents would be moved on Monday. Surveyor asked were families made aware the residents would be isolated on the unit behind a wall. SW R stated the wall was not initially put up; it was felt the residents needed more room to wander so the wall was put up to allow the residents more freedom. Surveyor asked SW R whose decision was it to erect the wall. SW R stated the IDT (Interdisciplinary Team) met and it was discussed, and the team all agreed this would allow the residents more freedom to wander. Surveyor asked SW R did anyone discuss the wall being erected with the families. SW R stated I am not sure. On 10/9/24 at 5:50 PM Surveyor interviewed NHA A (Nursing Home Administrator) regarding the room changes and the wall. NHA A stated the room changes were necessary as there were gaps in staff supervision of the three residents. NHA A stated the IDT met and decided to make the room changes to lower the ratio from staff to resident and try to protect the residents. Surveyor asked NHA A who decided to erect the wall. NHA A stated initially the staff had the fire doors closed and it was not allowing the residents enough space to wander. I ultimately made the decision; however, the IDT discussed the issue and we decided this would allow a safe space for the residents to walk and give them more freedom to walk the hall. We were acting on the best interest of the residents we did this to allow them more freedom. I feel like we just cannot make the right decision we need to protect residents but now are being told they cannot be in the space; I have no idea what we should do anymore. Surveyor asked NHA A if the families were told their loved ones would be behind the wall, NHA A stated yes. Surveyor asked NHA A if anyone had discussed their concerns about the wall or the space R1, R2 and R3 resided. NHA A stated all families were understanding and we are supporting them through this transition. R1, R2, and R3 have a history of resident-to-resident incidents, in effort to decrease the number of resident-to-resident incidents the facility relocated R1, R2 and R3 to a different location within the facility. The facility then erected an approximately six-foot wall and affixed the wall with brackets to the cement wall. This wall involuntarily secluded R1, R2, and R3 from the rest of the building and did not afford R1, R2, or R3 the same liberties and rights as all other residents in the facility. R1, R2, and R3 are not able to attend group activities or participate in other day to day activities in the facility. A reasonable person would be fearful, anxious, and feel dehumanized, when not afforded the individuality, compassion, and civility as others who reside at the facility.

Based on observation and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 64 Residents who reside in the facility. Kitchen floor was unclean with visible dirt and food debris on the floor. Dish machine rinse temperature did not reach the 180-degree rinse requirement. Evidenced by: Facility Policy titled 'Sanitization,' states in part: .The food service area shall be maintained in a clean and sanitary manner . 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. 4. Sanitizing of environmental surfaces must be performed with one of the following solutions: a. 50-11 ppm chlorine solution; 150-200ppm quaternary ammonium compound (QAC); or c. 12.5ppm iodine solution.15. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 16. the food services manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Facility policy titled 'Dishwashing Machine Use,' states in part: .2 Dishwashing machines that use hot water to sanitize must maintain the following wash solution temperatures: a. 150 F (degrees Fahrenheit) for stationary rack, dual temperature machines or multi-tank, conveyor, multi-temperature machines. b. 160 F (degrees Fahrenheit) for single tank, conveyor, dual temperature machines. c. 165 F for stationary rack, single temperature machines. d. if the temperature for the rinse is under 150 F, all dishes are to be washed twice. 3. Dishwashing machine hot water sanitation rinse temperatures may not be more than 194 F, or less than: a. 165 F for stationary rack, single temperature machines. b. 180 F for all other machines.7.The operator will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately.9. If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or PPM are adjusted. Manufacturer information, titled Technical Data High Temp Rinse, indicates in part: Directions for use: Final Rinse temperature should be maintained as close to the 180 degrees Fahrenheit minimum as possible, and should not exceed 190 degrees, in any case. October 2024 Sanitizer test log indicates the following: 10/3 AM shift is blank indicating the sanitizer was not tested 10/5 AM shift is blank indicating the sanitizer was not tested 10/6 AM shift is blank indicating the sanitizer was not tested 10/7 PM shift is blank indicating the sanitizer was not tested 10/8 PM shift is blank indicating the sanitizer was not tested October 2024 Dishwasher temp log indicates the following: 10/1 10:00 am Final rinse was 152 degrees, internal disk temp was 144.1, corrective action ran two times. PM (evening) final rinse was 156 degrees and internal disk temp 145.7, corrective action ran twice. 10/2 11:00 am Final rinse was 151.2 degrees, internal disk temp was 148.2, corrective action ran two times. PM (evening) final rinse was 156 degrees and internal disk temp 140, corrective action ran twice. 10/3 10:00 am Final rinse was 140.7 degrees, internal disk temp was 145, corrective action ran two times. PM (evening) final rinse was 159 degrees and internal disk temp 144, corrective action ran twice. 10/4 9:47 am Final rinse was 147 degrees, internal disk temp was 146.8, corrective action ran two times. PM (evening) final rinse was 136 degrees and internal disk temp 149, corrective action ran twice. 10/5 for day shift it's blank. PM (evening) final rinse was 159 degrees and internal disk temp 147, corrective action ran twice. 10/6 for day shift it's blank. PM (evening) final rinse was 149 degrees and internal disk temp 146, corrective action ran twice. 10/7 10:00 am Final rinse was 151 degrees, internal disk temp was 150.8, corrective action ran two times. PM is blank. 10/8 10:00 am Final rinse was 149 degrees, internal disk temp was 150.4, corrective action ran two times. PM is blank. On 10/9/24 at 6:44 AM, Surveyor observed the Kitchen with DA I (Dietary Aide). DA I indicated the kitchen is mopped and swept on Tuesdays and Thursdays. Surveyor observed the kitchen floor to have brownish black areas all over the floor along with food debris under prep stations, oven, three compartment sink and warming carts. The tile flooring near the drain had cracks in the tiles and a gouge in the tile near the dishwashing room door. DA I indicated the floors are not clean. On 10/9/24 at 7:04 AM, Surveyor interviewed DA E regarding the dish machine. DA E indicated the dish machine has a problem with filling and doesn't want to work right away. DA E indicated they test the temperatures in the middle after two carts go in. DA E indicated they use a temp disk in the middle of the rack. DA E indicated they have been running the dishes twice due to not reaching temperature. Surveyor observed the temperature log with DA E, and DA E indicated No, when Surveyor asked if the Dish machine was temping to 180 degrees for a rinse temp. DA E indicated the dish machine issue has been going on for about two weeks or so and maintenance is aware. DA E indicated they need more dietary staff, and the floors need to be cleaned more often. Surveyor observed the dish room floor to be dirty with brown and black discolored areas and debris. On 7/10/24 at 7:10 AM, Surveyor interviewed MNT T (Maintenance) regarding the dish room floor and kitchen floor. Surveyor asked MNT T if the floors looked clean, MNT T indicated the floor could be swept. On 10/9/24 at 7:40 AM, Surveyor observed the dish room, kitchen, and temperature logs with NHA A (Nursing Home Administrator). NHA A indicated based on the temperature log/form the dish machine was not temping correctly. Surveyor asked NHA A if the dishes were being sanitized properly if the dish machine temperature is not reaching the correct temperature, NHA A stated no. NHA A indicated they have had water heater issues recently. Surveyor reviewed temp log and sanitizer log noting blanks on the form, NHA A indicated the temperature log and sanitizer log are incomplete and should be completed. On 10/9/24 at 10:30 AM, Surveyor interviewed MNT U (Maintenance) regarding the water temps. MNT U indicated a boiler has been down and if the water is not 140 degrees when it hits the dish machine heat exchange, the exchange is not able to heat the water up the additional 40 degrees that is required, resulting in water temps not reaching the 180-degree rinse temperature. On 10/9/24 at 10:40 AM, Surveyor interviewed DM W regarding the dishwasher temperatures. DM W indicated they do dishes twice if the dish machine doesn't meet the 150-degree wash temperature. DM W indicated she has acknowledged that the floors haven't been getting done, usually (Staff Members Name) is here Tuesday and Thursday. DM W indicated she is working with a new staff member on deep cleaning tasks. DM W indicated if staff notice the kitchen is dirty, they should clean it.

Based on observation and interview, the facility did not ensure that each resident has a safe, clean, comfortable, and homelike environment, including, but not limited to receiving treatment and supports for daily living for 1 (R2) of 3 resident rooms observed. R2's bathroom toilet was soiled with stool and family reported it had been soiled for several days. This is evidenced by: On 10/8/24 at 6:45 PM, Surveyor observed R2's room and bathroom. R2's toilet was soiled with stool. On 10/9/24 8:20 AM, Surveyor observed R2's room and bathroom. R2's toilet was soiled with stool. On 10/9/25 at 8:15 AM, Surveyor met R2's Guardian FM K (Family Member) and Spouse. R2's guardian asked Surveyor if she had observed R2's bathroom. Surveyor observed R2's bathroom and noted the bathroom remained dirty with stool observed around and in the stool. FM K stated this has been like this for several days; the facility does not clean R2's bathroom or room. FM K stated she has had to clean R2's room because the facility does not. On 10/9/24 at 8:30 AM, Surveyor interviewed Hskp BB (Housekeeping) regarding cleaning of resident rooms. Hskp BB stated rooms are usually cleaned daily. Surveyor asked Hskp BB if she was aware R2's bathroom needed cleaning. Hskp BB stated she was not but would clean it if necessary. On 10/9/24 at 5:50 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding R2's bathroom. NHA A stated it has been cleaned.

Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of a facility-initiated discharge, failed to ensure the written notice contained all pertinent information for a discharge notice including the location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, and the name and address of the Office of the State Long-Term Care Ombudsman for 2 of 2 facility-initiated discharges reviewed involving 2 Resident (R1 and R2). R1 and R2 received involuntary discharge notices; however, the notices did not contain all necessary information. This is evidenced by: The facility's Transfer and/or Discharge Policy revised 3/2021 states in part: (2) residents are permitted to stay in the facility, and not be transferred or discharged unless: a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility . (3) except as specified below, the resident and his or her representative are given thirty day advance written notice of an impending transfer or discharge from the facility. (5) The resident and representative are notified in writing of the following information: a. the specific reason for transfer or discharge; b. the effective date of transfer or discharge; c. the location to which the resident is transferred or discharged ; d. an explanation of the resident's right to appeal the transfer or discharge to the state, including; (1) the name, address (mailing and email), and telephone number of the entity which receives such requests; (2) information on how to obtain, complete, and submit an appeal request; and how to get assistance completing the appeal process; f. the name, address, email and telephone number of the Office of the State Long-Term Care Ombudsman; i. the name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices. 6. A copy of the notice is to be sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. 7. Residents have the right to appeal a facility-initiated discharge or discharge through a state agency that handles appeals. A. If a resident chooses to appeal a discharge, the facility will not discharge residents while the appeal is pending. The facility posted a sign dated 9/30/24 for all staff. The sign states in part; In response to the last survey visit on 9/16/24. The only way to guarantee other residents are safe; we have issued a 30-day notice to (R1) and (R2). (R1) and (R2) will be housed in the Way unit. Not ideal but in order for us to have a chance of being cleared, this needs to happen. Example 1 R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, seizure disorder, depression, and insomnia. R1's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R1 has a Brief Interview for Mental Status (BIMS) of 0 out of 15, indicating R1 is severely cognitively impaired. Section E indicates that out of the last 7 days R1 has behavioral symptoms toward others 1-3 days, Verbal Symptoms toward others 1-3 days, behavioral symptoms not directed toward other 1-3 days, rejection of care 1-3 days, and wanders 1-3 days. Impact to resident and other residents is blank. Section GG indicates R1 is dependent for toileting hygiene, showers, upper and lower body dressing, and personal hygiene. On 10/2/24, the facility issued R1's family a document titled Facility-Initiated Discharge which states in part; this is to notify you of an upcoming move and your rights. Date written notice mailed/Given: 10/2/24. Resident Representative Name: FM S (Family Member/legal name). You will be moved from: (Facility Name). To: To be determined. The expected move date/time is: 11/7/24. The purpose of the move: Under CFR (s): 483:14 (C) (1) Facility requirements-(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless, the facility entered, unable to safely care for resident. (Facility Name) understands that moving can be a big change for some individuals, and every care is taken in making the right decision for all our residents. However, you do have the right to contest this decision and contact your local ombudsman about this move. The Ombudsman Contact Information is Email: BOALTC@wisconsin.gov. Phone: [PHONE NUMBER]. Staff Certifying resident/resident representative understanding prior to discharge: Name Printed: FM S signed the document. Signature: FM S Date copy of notice sent to Ombudsman: 10/2/24. Of note the above document does not contain the following: A copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Although the document states it was sent to the Ombudsman, interview with the Ombudsman states the BOALTC (Board on Aging and Long-term Care) office did not receive the notice. The location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. (Emphasis intended). R1's progress notes state the following: 10/2/2024 14:41 (2:41 PM) Meeting this date with resident's husband to discuss that placement is needed in a more dementia specific placement due to unable to meet her needs safely. 30-day notice given this date including ombudsman contact information. (Resident Husband) requests that transfer plans be completed with (R1's) daughter (daughter's name). 10/2/2024 15:47 (3:47 PM) Facility initiated room change form and facility-initiated discharge notices were emailed to (Ombudsman Name) this date. 10/2/2024 15:48 (3:48 PM) This writer spoke with resident's daughters per phone to discuss 30-day notice and what facilities they would like contacted for placement. Facility that (daughter's name) works at does not have dementia care. (Daughter's name) will investigate facilities in [NAME] County so referrals can be made. Placement needs to accept medical assistance for payment. 10/4/2024 13:22 (1:22 PM) Epic sent to Dr. (name) I am writing to inform you about an important development regarding resident, who has been under our care at (facility name). After careful evaluation, we have determined that she will be receiving a facility-initiated 30-day discharge notice due to a lack of appropriateness for skilled nursing care. Throughout resident's stay, our interdisciplinary team has closely monitored her clinical needs and progress. While we have made every effort to provide the necessary support, it has become increasingly evident that she no longer meets the criteria for skilled nursing facility placement. This decision was reached based on observations and assessments which indicate that she would be better served in a different care setting such as an Alzheimer's/Dementia facility. We are committed to ensuring a smooth transition for resident. During the 30-day notice period, we will work collaboratively with you, resident's case worker, the resident, and any involved family members to develop a comprehensive discharge plan that prioritizes her health and well-being. Please let us know if you have any questions or concerns about this decision or if you would like to discuss potential options for next steps. Could you please write a discharge order and statement of support of this plan? On 10/8/24 at 8:12 PM, Surveyor interviewed FM J (Family Member) regarding R1's 30-day FID (Facility-Initiated Discharge). FM J stated on 10/2/24, FM J and her sister were looped into a meeting with SW R (Social Worker) and FM S. SW R told us a 30-day notice was being given to (R1) due to her aggression and going into other residents' rooms. The facility felt (R1) would be better off if she was on a memory care unit. This was a huge shock, we understand R1 has confusion with her dementia and wanders. We were just shocked they were making us find another place for (R1). We were told it was our responsibility to find a suitable place for (R1). Surveyor asked FM J if she or FM S received a written notice. FM J stated FM S has the written notice. Surveyor asked if the written notice contained information on how to appeal the 30-day notice? FM J stated she did not think there was any information regarding appeal rights or how to appeal the FID/30-day IVDN (involuntary discharge notice). FM J stated no one discussed that the family had the right to appeal. FM J stated this is just so hard and devastating, FM S visits (R1) every day, if we have to move (R1) FM S will not be able to visit her daily. FM J stated everyone knows moving a person with dementia can be so devastating to them and their quality of life, I just don't understand this, I thought all nursing homes cared for residents with dementia. FM J stated have you looked at the facility website, they advertise they have a Dementia Stabilization Unit, I know this is not part of the nursing home, but they have this unit and can care for dementia residents, but they can't in the nursing home; it doesn't make sense. On 10/9/24 at 8:35 AM, Surveyor interviewed SW R (Social Worker) regarding the 30-day IVDN for R1. Surveyor asked SW R what she knew regarding the 30-day notice for R1. SW R stated R1 was involved in multiple resident-to-resident incidents, R1 had 1:1 staffing on the previous unit and even with the individualized staffing R1 was ambulatory and fast enough to still have incidents with other residents. Surveyor asked SW R if she was involved in creating and giving the 30-day IVDN; SW R stated the IDT (Interdisciplinary Team) met to discuss R1 and it was agreed upon that R1 would need a 30-day IVDN. SW R stated the IVDN was being given with hopes R1 could be discharged to a dementia specific placement and smaller environment. SW R stated she met with R1's husband, and via phone with R1's daughters to discuss the 30-day discharge. SW R stated R1's husband did ask that we get R1's daughter involved as he stated he was not young and R1 should be discharged closer to where the daughters live. SW R stated she met with R1's husband at least once after the call as R1's husband was concerned R1 would be kicked out of the facility. Surveyor asked SW R who is making discharge arrangements for R1? SW R stated the facility would assist but R1's daughter was interested in assisting with the arrangements. On 10/9/24 at 10:00 AM, Surveyor met with FM S and FM J. FM S stated he was upset about (R1) receiving the discharge notice. FM S began to get tearful and stated I feel like I failed (R1) I just can't take care of her. FM S stated I visit her every day; I will not be able to do that if she moves. Can they just kick her out, what if she goes somewhere else can they give us a 30-day notice then where will she go. Surveyor interviewed NHA A (Nursing Home Administrator) regarding the 30-day IVDN for R1. NHA A stated she made the decision to give the 30-day IVDN as R1 is stable and no longer in need of skilled nursing care. NHA A stated R1 wants to touch people, she worked here, and it is very difficult for her adjusting to not working here. Surveyor asked NHA A who crafted the 30-day IVDN? NHA A stated she went line by line with the regulation when preparing the document. Surveyor asked NHA A did the 30-day IVDN include where the resident would be discharged to, the resident's appeal rights, including the name, address (mailing and email), and telephone number for DQA and the Regional Director, information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. NHA A stated, I followed the regulation, and the information was on the form for the Ombudsman, and we did send it. On 10/9/24 at 9:15 AM, Surveyor spoke with Ombudsman C. Ombudsman C indicated she did not receive notice of R1 and R2's 30-day involuntary discharge notices. Ombudsman C indicated she received an email from SW R (Social Worker) on 9/27/24 around 4:41PM indicating they had 2 dementia residents that SW R issued notice of a move to another hall. Ombudsman C indicated she did not receive correspondence on which hall or where the residents were moved to. Ombudsman C indicated she received a call from SW R on 10/1 regarding residents not being qualified for the DSU (Dementia Stabilization Unit) and was asking for assistance. Ombudsman C indicated she referred them to the Alzheimer's Association for ideas. Example 2 R2 was admitted on [DATE] with diagnoses that include Alzheimer's, dementia, muscle weakness, and unsteadiness on feet. R2's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R2 has a Brief Interview for Mental Status (BIMS) of 0 out of 15, indicating R2 is severely cognitively impaired. Section B indicates R2 hears adequately, has clear speech, usually makes self-understood, and usually understands others. Section E indicates that R2 has not had rejection of cares, physical, verbal, or other behavioral symptoms, or wandering in the last 7 days. Impact to Resident and other residents is blank. Section GG indicates R2 needs supervision or touching assistance with toileting hygiene, showers, lower body dressing, and personal hygiene. R2 is independent with sitting to lying, lying to sitting, sitting to standing and transferring from chair to bed or bed to chair, toileting, and walking. On 10/2/24, the facility issued R2's family a document titled Facility-Initiated Discharge which states in part; this is to notify you of an upcoming move and your rights. Date written notice mailed/Given: 10/2/24. Resident Representative Name: FM K (Family Member/legal name). You will be moved from: (Facility Name). To: To be determined. The expected move date/time is: 11/7/24. The purpose of the move: Under CFR (s): 483:14 (C) (1) Facility requirements-(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless, the facility entered, unable to safely care for resident. (Facility Name) understands that moving can be a big change for some individuals, and every care is taken in making the right decision for all our residents. However, you do have the right to contest this decision and contact your local ombudsman about this move. The Ombudsman Contact Information is Email: BOALTC@wisconsin.gov. Phone: [PHONE NUMBER]. Staff Certifying resident/resident representative understanding prior to discharge: Name Printed: FM K signed the document. Signature: FM K Date copy of notice sent to Ombudsman: 10/2/26. Of note the above document does not contain the following: A copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Although the document states it was sent to the Ombudsman, interview with the Ombudsman states the BOALTC (Board on Aging and Long-term Care) office did not receive the notice. The location to which the resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. (Emphasis intended). Progress notes dated Facility-initiated Room Transfer, states in part: Resident name: (R2). Date written Notice Given or mailed (circle one): 9-27-24 per phone. Resident Representative Name (if applicable): (FM K (Family Member)). This is to notify you of an upcoming move within the facility to another room within the facility. You will be moved from: Room number (number) on View unit to Room Number (number) on way unit. The expected move date/time is: 9-30-24. Date, (time is blank).The purpose of the move: Smaller unit to control behaviors affecting others and allow wandering . Progress notes dated 10/4/2024 13:23 (1:23PM) Epic sent to Dr. (name) I am writing to inform you about an important development regarding resident, who has been under our care at (facility name). After careful evaluation, we have determined that she will be receiving a facility-initiated 30-day discharge notice due to a lack of appropriateness for skilled nursing care. Throughout resident's stay, our interdisciplinary team has closely monitored her clinical needs and progress. While we have made every effort to provide the necessary support, it has become increasingly evident that she no longer meets the criteria for skilled nursing facility placement. This decision was reached based on observations and assessments which indicate that she would be better served in a different care setting such as an Alzheimer's/Dementia facility. We are committed to ensuring a smooth transition for resident. During the 30-day notice period, we will work collaboratively with you, resident's case worker, the resident, and any involved family members to develop a comprehensive discharge plan that prioritizes her health and well-being. Please let us know if you have any questions or concerns about this decision or if you would like to discuss potential options for next steps. Could you please write a discharge order and statement of support of this plan? On 10/9/24 at 8:55 AM, Surveyor interviewed FM K (Family Member) regarding R2's 30-day FID (Facility-Initiated Discharge). FM K stated on 10/1/24, FM K had a meeting with the SW R (Social Worker), SW R stated they were moving (R2) elsewhere, and a 30-day involuntary discharge notice (IVDN) was being given to (R2). FM K stated she was told they reason for the 30-day IVDN was because (R2) was causing the facility to receive too many citations. FM K stated I was so upset; I could not believe this was happening. FM K stated I know (R2) touches people and then (R2) will get hit or R2 will want to hug someone, and the other person does not like it and then there is slaps exchanged. FM K stated the facility told her they were doing 1:1 with (R2) and it was not working, I never saw staff doing 1:1 and I am here a lot. FM K stated the facility stated (R2) would be better off if she was on a memory care unit. I was beside myself and just completely shocked to hear they were making us find another placement for (R2). Surveyor asked FM K if she received a written notice. FM K stated she has the written notice. Surveyor asked if the written notice contained information on how to appeal the 30-day notice? FM K stated she did not think there was any information regarding appeal rights or how to appeal the FID/30-day IVDN. FM K stated no one discussed that the family had the right to appeal. FM K stated what nursing home doesn't care for a resident with dementia, this just does not seem right to me. On 10/9/24 at 8:35 AM, Surveyor interviewed SW R (Social Worker) regarding the 30-day IVDN for R2. Surveyor asked SW R what she knew regarding the 30-day notice for R2. SW R stated R2 was involved in multiple resident-to-resident incidents, R2 had 1:1 staffing on the previous unit and even with the individualized staffing R2 was ambulatory and fast enough to still have incidents with other residents. Surveyor asked SW R if she was involved in creating and giving the 30-day IVDN? SW R stated the IDT (Interdisciplinary Team) met to discuss R2 and it was agreed upon that R2 would need a 30-day IVDN. SW R stated the IVDN was being given with hopes R2 could be discharged to a dementia specific placement and smaller environment. SW R stated she met with R2's daughter to discuss the 30-day discharge. Surveyor asked SW R who is making discharge arrangements for R2? SW R stated the facility will assist and work with R2's managed care organization. Surveyor interviewed NHA A (Nursing Home Administrator) regarding the 30-day IVDN for R2. NHA A stated she made the decision to give the 30-day IVDN as R2 is stable and no longer in need of skilled nursing care. NHA A stated R2 has been here a long time and the amount of supervision needed would be very restrictive for R2. Surveyor asked NHA A who crafted the 30-day IVDN? NHA A stated she went line by line with the regulation when preparing the document. Surveyor asked NHA A did the 30-day IVDN include where the resident would be discharged to, the resident's appeal rights, including the name, address (mailing and email), and telephone number for DQA and the Regional Director, information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman. NHA A stated I followed the regulation, and the information was on the form for the Ombudsman, and we did send it. On 10/9/24 at 9:15 AM, Surveyor spoke with Ombudsman C. Ombudsman C indicated she did not receive notice of R1 and R2's 30-day involuntary discharge notices. Ombudsman C indicated she received an email from SW R (Social Worker) on 9/27/24 around 4:41 PM indicating they had 2 dementia residents that SW R issued notice of a move to another hall. Ombudsman C indicated she did not receive correspondence on which hall or where the residents were moved to. Ombudsman C indicated she received a call from SW R on 10/1/24 regarding residents not being qualified for the DSU (Dementia Stabilization Unit) and asking for assistance. Ombudsman C indicated she referred them to the Alzheimer's Association for ideas.

Based on observation, interview, and record review, the facility failed to provide an ongoing program to support resident choice of activities, based on the comprehensive assessment and care plan and the preferences of each resident for 3 of 3 Residents (R1, R2, R3) residing on the Way Unit. Activity staff and staff working on the Way Unit were not providing or offering activities for R1, R2, and R3. There is no documentation of R1, R2, and R3 participating or being offered activities since they were moved to the Way Unit. This is evidenced by: Facility Policy entitled 'Individual Activities and Room Visit program,' states in part: .Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities and for those residents who do not wish to attend group activities. Residents who are able to maintain an independent program will have supplies available to them.1. individual activities are provided for individuals who have conditions or situations that prevent them from participating in group activities, or who do not wish to do so. 2. For those residents whose condition or situation prevents participation in group activities, and for those who do not wish to participate in group activities, staff provides individualized activities consistent with the overall goals of an effective activities program. 3. Individualized activities offered are reflective of the resident's comprehensive care plan. 4. it is recommended that residents with in-room activity programs receive, at a minimum, three in -room visits per week. A typical in-room visit is ten to fifteen minutes in length but may be longer if appropriate for the resident. 5. Activities for residents with behavioral or emotional problems who cannot participate in group activities include: a. uncomplicated activities that can be adapted to the level of the individual's attention span and function; b. activities requiring short periods of concentration to reduce frustration; and c. activities tailored to address specific underlying causes of the individuals behavioral or attention limitations (e.g.; familiar occupation-related activities, exercise and movement activities, engaging the resident in conversation, and using one-to-one activities such as looking at familiar pictures and photo albums). 6. Residents who choose not to attend group activities are encouraged to participate in independent activities. It is the responsibility of the facility and the activity staff to make regular contact with residents who choose to pursue independent activities, maintain appropriate records and offer supplies, as needed. Example 1 R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Seizure disorder, Depression, and Insomnia. R1's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R1 has a Brief Interview of Mental Status (BIMS) of 0 out of 15, indicating R1 is severely cognitively impaired Section E indicates that out of the last 7 days R1 has behavioral symptoms toward others 1-3 days, Verbal Symptoms toward others 1-3 days, behavioral symptoms not directed toward other 1-3 days, rejection of care 1-3 days and wanders 1-3 days. Impact to Resident and other residents is blank. Section GG indicates R1 is dependent for toileting hygiene, showers, upper and lower body dressing, and personal hygiene. R1's Activity Care Plan, states in part: I am dependent on staff for meeting emotional, intellectual, physical and social needs r/t (related to) dementia and cognitive deficits . Goal: I will maintain involvement in cognitive stimulation, social activities as desired through review date .Interventions/Tasks: All staff to converse with me while providing care .Establish and record my prior level of activity involvement and interests by talking with me, caregivers, and family on admission and as necessary. Read my background sheet with my history . I need assistance with ADL's as required during the activity .I needs [sic] assistance/escort to activity functions . I prefer activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as music, crafts, baking .introduce me to residents with similar background, interests and encourage/facilitate interaction .invite the me [sic] to scheduled activities .my preferred activities are: Crafts, baking, laundry, music, old movies, old shows [NAME] and Waltons, watching sports (basketball and football), casino games, cats and dogs .Provide a program of activities that is of interest and empowers me by encouraging/allowing choice, self-expression and responsibility. I was a caregiver and enjoy helping others .Provide me with materials for individual activities as desired. I like the following independent activities. Combining material pieces into a quilt pattern, sorting items, creating a design .when I choose not to participate in organized activities, I prefers [sic] to visit for social and sensory stimulations . On 10/9/24, during record review, Surveyor was unable to locate documentation of activity attendance or declination, in R1's Record. Example 2 R2 was admitted on [DATE] with diagnoses that include Alzheimer's, restless leg syndrome, Dementia, muscle weakness, and unsteadiness on feet. R2's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R2 has a Brief Interview of Mental Status (BIMS) of 0 out of 15, indicating R2 is severely cognitively impaired. Section B indicates R2 hears adequately, has clear speech, usually makes self-understood, and usually understands others. Section E indicates that R2 has not had rejection of cares, physical, verbal, or other behavioral symptoms, or wandering in the last 7 days. Impact to Resident and other residents is blank. Section GG indicates R2 needs supervision or touching assistance with toileting hygiene, showers, lower body dressing and personal hygiene. R2 is independent with sitting to lying, lying to sitting, sitting to standing and transferring from chair to bed or bed to chair, toileting, and walking. R2's Activity Care plan states in part: I have impaired cognitive function/dementia or impaired thought process r/t (related to) dementia .Goal: I will maintain current level of decision making ability by choosing my meals, clothing and bedtime by review date .I will be able to communicate basic needs on a daily basis through the review date . interventions/tasks: .engage me in simple, structured activities that avoid overly demanding tasks. I prefer to fold towel and napkins and sorting items like buttons (4/4/23). I need assistance with all decision making . Present just one thought, idea, question, or command at a time . provide a program of activities that accommodates my abilities .provide me with a homelike environment: likes to talk about her quilts she made, and her pictures of family on bulletin board .Reminisce with me using photos of family and friends . On 10/9/24, during record review, Surveyor was unable to locate documentation of activity attendance or declination, in R2's Record. Example 3 R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, chronic pain, delusional disorders, major depression, anxiety, and adjustment disorder. R3's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R3 has a Brief Interview of Mental Status (BIMS) of 0 out of 15, indicating R3 is severely cognitively impaired Section E indicates that out of the last 7 days 1-3 days, behavioral symptoms not directed toward other. Section GG indicates R3 is supervision/maximum assistance for toileting hygiene, showers, dressing, and personal hygiene. R3's Activity Care plan states in part: I am dependent on staff for meeting emotional, intellectual, physical, and social needs r/t (related to) Advanced Alzheimer's. (date initiated: 2/28/23, revision on: 9/6/24). Goal: I will attend/participate in activities as able through review date as I have advanced Alzheimer .target date 12/10/2024.Interventions/tasks: All staff to converse with me while providing care (2/28/23). Encourage ongoing family involvement. invite my family to attend special events, activities, meals .I needs [sic] assistance/escort to activity functions .I prefer activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities (Revision 9/6/24) .Invite the me [sic] to scheduled activities. I may not stay at activities long as I have advanced Alzheimer and inattention. I like to be moving. (Revision 9/6/24). My preferred activities are 1:1, sitting in the common area with groups of people, listening to music, walking with a staff member, rolling a yarn ball, caring for baby doll. I also enjoy having snacks and drinks between meals. I like comfort care from the staff such as warm blankets, hand holding, massages. I enjoy when my family comes to visit. (revision 9/6/24). R3's Activities - Quarterly/annual participation review form indicates: Attendance and participation summary. 1. Described the residents attendance preferences and participation [sic] level with activities (group, event, 1:1). Resident does not attend many activities. Staff tries to bring her to them, but she usually leaves. Activity plan review: Describe changes to interventions/approaches: We're trying to do new activities and approaches [sic] with resident. On 10/9/24, during record review, Surveyor was unable to locate documentation of activity attendance or declination, in R3's record. On 10/9/24 at 8:40 AM, Surveyor interviewed ACT F (Activity Staff) regarding the way unit. ACT F indicated R1, R2, and R3 were moved for the safety of other residents. ACT F indicated she has not been on the unit other than she (ACT F) took down activities for them to do such as sensory items, puzzles, coloring items, and a large balloon ball. ACT F is unaware if someone is doing activities with them on the unit and to ask ACT G. On 10/9/24 at 8:44 AM, Surveyor interviewed ACT G regarding activities for R1, R2, and R3. ACT G indicated she is the Life Enrichment Director. ACT G indicated they have coloring, music, Lego's, puzzles, and items to keep their hands busy down on the unit available. Surveyor asked ACT G if anyone from activities is doing activities with R1, R2, and R3 on that unit, ACT G stated, No. ACT G indicated she was told they're not responsible for activities on the way unit, and she can only assume the CNAs are doing activities with them. ACT G indicated they do an activity from 10 AM to 11 AM and 2 PM to 3 PM on other units each day. Surveyor asked ACT G who would be documenting participation of activities or if they were offered for R1, R2, and R3. ACT G indicated she was not aware if the CNAs were told they are to do activities with the residents or if they are documenting it. On 10/9/24 at 9:00 AM, Surveyor interviewed CNA V regarding the way unit. Surveyor asked about activities and CNA V indicate she was not sure if they're being done or if doing 1:1 like upstairs. (Of note: R1, R2, and R3 were previously on a unit that offered 1:1 with residents.) On 10/9/24 at 8:56 AM, Surveyor interviewed RA/CNA Q (Resident Assistant/Certified Nursing Assistant) about activities on the unit. RA Q indicated staff do some activities like coloring. RA Q indicated she is not aware of any activity staff coming down to the unit. RA Q indicated that R2 will color with staff, R1 will listen to music in her room and R3 is more 1:1 as she's up and down a lot. RA Q indicated she's alone on the unit and the nurse comes with medications and when needed. RA Q indicated she is not able to do 1:1 activity with all three Residents. On 10/9/24 at 10:20 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A if activity staff are doing activities on the unit, NHA A indicated they are. Surveyor asked for activity documentation prior to today (10/9/24) for R1, R2, and R3. On 10/9/24 at 4:15 PM, Surveyor interviewed RA H regarding the way unit. RA H indicated she works the way unit and works three times per week. RA H stated, I'm just an RA, I can't do physical care, and indicated she has access to a unit phone. RA H indicated she passes out the meals and does 15-minute checks on R1, R2, and R3. Surveyor asked RA H about activities, RA H indicated during the day shift they (R1, R2, and R3) usually sleep and that RA H hasn't done activities with them. RA H indicated she was not sure if anyone does activities with them. RA H indicated she leaves at 3pm On 10/9/24 at 6:24 PM, Surveyor interviewed BOM Z (Business Office Manager), who over sees the activity department. Surveyor asked BOM Z if there is documentation of activities being offered, declined or how much R1, R2, and R3 participated in the activity, BOM Z indicated that staff chart under a progress note in the computer under activities. Surveyor brought up R1, R2, R3's notes. No daily documentation was documented from 10/1 to current. BOM Z indicated in the last 6 weeks or so staff started putting notes in regarding 1:1, if any concerns are expressed or if it was a good visit etc., Surveyor asked what staff are to do if a resident declines/refuses an activity, BOM Z indicated document it. BOM Z indicated they had three activity staff working daily. BOM Z indicated the activity calendar is put together based on resident input. Surveyor asked if R1, R2, and R3 are offered the same activities as the other residents, BOM Z indicated they don't sit down and participate as they're antsy. BOM Z indicated that ACT F brought items down. BOM Z indicated she is not sure if CNA's document activities being provided or if they're aware how to document activity participation. On 10/9/24 at 6:45 PM, Surveyor asked NHA A again for documentation for activity participation or documentation that activities are being offered to R1, R2, and R3 from 10/1/24 to current. Two staff statements dated 10/9/24 were provided to Surveyor indicating the following: Employee CNA N, I provided the following activities with R3, R2, and R1: I walked with R3, R1 and I colored together; I walked with R2 and colored with her. Signature: verbal statement obtained from CNA N on 10/9/24 at 10:30 (am) date: 10/9/24, signed by DON B (Director of Nursing) (of note the statement does not indicate what day or shift this occurred, and it was not documented in their medical record) Staff statement: Employee: CNA Y, I provided the following activities with R3, R2, and R1 on 10/4/24 night shift: R3 went to the bathroom and slept all night. R1 slept all night; I walked with R2 and watched the movie Friday with her. (Of note: no documentation was provided from 10/1/24 to 10/9/24 to show R1, R2, and R3 are receiving activities daily or if they did/did not participate in the activity that was offered or if 1:1 activity was provided.)

Based on interview and record review, the facility failed to assure that there is sufficient, qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for 3 of 3 Residents (R1, R2, & R3). RA (Resident Assistants), who are not Certified Nursing Assistants, were working on the Way Unit alone with R1, R2 and R3 who require increased supervision. This is evidenced by: Facility Employee list shows RA H, RA CC, RA X, and RA AA as being RA's and CNA (Certified Nursing Assistant) Facility staffing schedule indicates the following: On 10/1/24, RA H worked 6:30 AM to 3:00 PM, on the Way Unit and RA CC worked the Way Unit from 3:00 PM to 4:00 PM with another RA training. On 10/2/24, RA CC worked 1:30 PM to 10:00 PM on the Way Unit. No indication on the schedule of a CNA being assigned to the Way Unit during this time. On 10/5/24, RA H worked from 6:30 AM to 3:00 PM, no indication on the schedule who was assigned to the Way Unit or if a CNA worked on the Way Unit during this time. (Per RA H's interview RA H worked on the Way Unit on 10/5/24). RA X and RA AA (training) worked 2:30 PM to 7:00 PM indicated as being on the Way Unit. On 10/6/24, RA H worked 6:30 AM to 3:00 PM, per the schedule on the Way Unit. RA X worked 2:30 PM to 9:00 PM on the Way Unit while training RA AA who worked 2:30 PM to 11:00 PM. No indication on the schedule of a CNA being assigned to the Way Unit during that time. On 10/7/24, RA H worked on the Way Unit from 6:30 AM to 3:00 PM, no indication on the schedule of CNA working the Way Unit during that time. Way is hand written next to RA H's time on the schedule. On 10/9/24 at 8:55 AM, Surveyor interviewed FM K (Family Member) regarding the Way Unit. FM K indicated RA H worked alone on the unit on Saturday (10/5) and Sunday (10/6). FM K indicated other RA's have also worked alone on the Way Unit. On 10/9/24 at 10:20 AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A for RA H, RA X, and RA AA's CNA registry as of today. NHA A indicated those three are not CNA's. Surveyor asked how RA's get help on the unit, NHA A indicated they have a phone and call the View Unit for assistance. NHA A indicated just this week they have a full time CNA on the unit for safety reasons. NHA A indicated RAs are not able to do hands on care. Surveyor asked if one the residents on the Way Unit were falling or had an emergency could the RA help them, NHA A indicated no. NHA A indicated there are no RAs on that unit now. On 10/9/24 at 4:15 PM, Surveyor interviewed RA H regarding the Way Unit. RA H indicated she works the Way Unit and works three times per week. RA H stated, I'm just an RA, I cannot do physical care, RA H indicated she had access to a unit phone to get assistance if needed. RA H indicated she passes out the meals and does 15-minute checks on R1, R2 and R3. RA H indicated she cannot put her hands on the residents but would try to reroute them or try to distract them if an incident were to occur. RA H indicated when all three residents (R1, R2, and R3) are awake they need to be line of sight and that RA H is only one person and doesn't feel it's safe to have just one person/RA on the Way Unit. RA H indicated they keep the double doors shut and alarms on R1, R2 and R3's bedroom doors. RA H indicated she would prefer a CNA to be down on the unit so there are 2 people. RA H indicated that the View nurse came down Saturday (10/5) and on Sunday (10/6), R2 became physical and verbal towards her. RA H indicated she called the nurse for help, and no one answered the phone. Surveyor asked RA H if she's received training on dementia care or behaviors, RA H indicated no. RA H indicated they are short of staff, and she feels management is testing the waters on RA's being alone on the unit. RA H indicated she was to be done at 3:00 PM; however, there was not a designated person to cover the unit on Sunday or Monday as they didn't have coverage. RA H expressed that if there is only one person on the unit and that person is in a room, who's watching the other two residents. Calls placed to RA X and RA AA; Surveyor was unable to reach them for an interview. The facility is not ensuring a Certified Nursing Assistant is assigned each shift to provide cares for R1, R2, and R3.

Based on interview and record review the facility did not afford the resident or resident's representative the right to refuse to transfer to another room in the facility for 3 of 3 residents (R1, R2 and R3) reviewed for room transfers. R1, R2, and R3 received room change notices and the facility did not afford the residents' representatives the opportunity to refuse the room change. This is evidenced by: The facility's policy titled Room Change/Roommate Assignment revised 3/2021 states in part; changes in room or roommate assignment are made when the facility deems it necessary or when the resident requests the change. 1. Resident room or roommate assignment may change if the facility deems it necessary. Resident preferences are taken into account when such changes are considered. 2. Room changes initiated by the facility are limited to moves with the same building in which the resident currently resident resides unless the resident voluntarily agrees to move to another building within the same facility. Prior to changing a room or roommate assignment all parties involved in the change/ assignment (e.g., residents and their representatives) are given at least a 4-hour advance notice of such change. 5. Residents have the right to refuse to move to another room in the facility if the purpose of the move is: a. to relocate a resident of a skilled nursing unit within the facility to one that is not a skilled nursing unit; b. to relocate a resident of a nursing unit with the facility to one that is a skilled nursing unit; or solely for the convenience of staff. The facility posted a sign dated 9/30/24 for all staff the sign states in part; In response to the last survey visit on 9/16/24. The only way to guarantee other residents are safe; we have issued a 30-day notice to (R1) and (R2). (R1), (R2) and (R3) will be housed in the Way unit. Not ideal but in order for us to have a chance of being cleared, this needs to happen. Example 1 R1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Seizure disorder, Depression, and Insomnia. R1's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R1 has a Brief Interview of Mental Status (BIMS) of 0 out of 15, indicating R1 is severely cognitively impaired Section E indicates that out of the last 7 days R1 has behavioral symptoms toward others 1-3 days, Verbal Symptoms toward others 1-3 days, behavioral symptoms not directed toward other 1-3 days, rejection of care 1-3 days and wanders 1-3 days. Impact to Resident and other residents is blank. Section GG indicates R1 is dependent for toileting hygiene, showers, upper and lower body dressing, and personal hygiene. On 9/27/24, the facility issued a document to R1's husband that states in part: Facility-Initiated Room Transfer. Resident Name: (R1). Date of written notice given or mailed: 9/27/24 (per phone). Resident Representative Name: FM S (Family Member) name, R1's AHCPOA (Activated Health Care Power of Attorney). This is to notify you of an upcoming move with the facility to another room within the facility. You will be moved from Room Number (room number) on Lane Unit to Room Number (Room Number) on the Way unit. The expected move date is 9/30/24. Family friends are welcome to assist with the move, but staff are available to move belongings as needed. The purpose of the move: Smaller unit to control behaviors affecting others and allow wandering. (Facility Name) understand that moving rooms can be a big change for some individuals, and every care is taken in making the right decision for all of our residents. However, you do have the right to contest this decision and contact your local Ombudsman about this move. The Ombudsman covering this area is: The Ombudsman for [NAME] County is: (Ombudsman C's Name) Email: (Email address) and Phone (Phone Number). On 10/8/24 at 8:12 PM, Surveyor interviewed FM J (Family Member) regarding R1's FIRC (Facility-Initiated Room Change). FM J stated on Friday 9/27/24, the facility contacted (R1's) AHCPOA FM S regarding the FIRC. FM S was told that R1 and two other residents would be moving to a different part of the facility. FM S received this call late in the afternoon on Friday 9/27/24. FM J stated FM S was not given an explanation for the reason for the transfer and the family did not know why this was occurring. Surveyor asked FM J if she or FM S were given the right to refuse the room transfer and FM J stated I did not hear we had that right. It happened quickly and (R1) was moved early Monday morning. On 10/9/24 at 10:00 AM, Surveyor met with FM S and FM J. FM S stated he received a call on Friday that they were moving (R1); I do not recall if they stated why. I was told I had to come in and sign a paper before Monday which I did. Surveyor asked FM S do you recall the facility mentioning to you, you could refuse the transfer. FM S stated he was not aware he could refuse. FM J stated it all happened so fast we wouldn't have known we had the right to refuse. Example 2 R2 was admitted on [DATE] with diagnosis that include Alzheimer's, Dementia, muscle weakness and unsteadiness on feet. R2's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R2 has a Brief Interview of Mental Status (BIMS) of 0 out of 15, indicating R2 is severely cognitively impaired. Section B indicates R2 hears adequately, has clear speech, usually makes self-understood, and usually understands others. Section E indicates that R2 has not had rejection of cares, physical, verbal, or other behavioral symptoms, or wandering in the last 7 days. Impact to Resident and other residents is blank. Section GG indicates R2 needs supervision or touching assistance with toileting hygiene, showers, lower body dressing and personal hygiene. R2 is independent with sitting to lying, lying to sitting, sitting to standing and transferring from chair to bed or bed to chair, toileting, and walking. On 9/27/24, the facility issued a document to R2's responsible party that states in part: Facility-Initiated Room Transfer. Resident Name: (R2). Date of written notice given or mailed: 9/27/24 (per phone). Resident Representative Name: FM K (Family Member) name, R2's Guardian. This is to notify you of an upcoming move with the facility to another room within the facility. You will be moved from Room Number (room number) on Lane Unit to Room Number (Room Number) on the Way unit. The expected move date is 9/30/24. Family friends are welcome to assist with the move, but staff are available to move belongings as needed. The purpose of the move: Smaller unit to control behaviors affecting others and allow wandering. (Facility Name) understand that moving rooms can be a big change for some individuals, and every care is taken in making the right decision for all of our residents. However, you do have the right to contest this decision and contact your local Ombudsman about this move. The Ombudsman covering this area is: The Ombudsman for [NAME] County is: (Ombudsman C's Name) Email: (Email address) and Phone (Phone Number). On 10/9/24 at 8:55 AM, Surveyor interviewed FM K regarding R2's FIRC (Facility-Initiated Room Change). FM K stated she received a call on Friday 9/27/24 at approximately 3:30. FM K stated she was on vacation up north when she received the call from SW R (Social Worker). FM K stated she was told the facility was moving (R2) to see how that would work to prevent incidents. FM K stated I thought this was awful (R2) has severe dementia and moving her would likely make things worse not better. FM K stated she was also told on Friday if this did not work the facility would be requesting the family look at moving (R2) elsewhere. Surveyor asked FM K if she was told she had the right to refuse the room change and FM K stated she did not receive that information. I was only told I needed to sign the paper by Monday. I came in Sunday night and signed the paperwork. FM K stated I came in very, early Monday morning and was shocked they had already moved (R2) to the other unit. I wouldn't even have had time to refuse the move. Example 3 R3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, chronic pain, delusional disorders, major depression, anxiety, and adjustment disorder. R3's Quarterly Minimum Data Set (MDS) dated [DATE] indicates R3 has a Brief Interview of Mental Status (BIMS) of 0 out of 15, indicating R3 is severely cognitively impaired Section E indicates that out of the last 7 days 1-3 days, behavioral symptoms not directed toward other. Section GG indicates R3 is supervision/maximum assistance for toileting hygiene, showers, dressing, and personal hygiene. On 9/27/24 the facility issued a document to R3's AHCPOA (Activated Health Care Power of Attorney) FM L (Family Member) that states in part: Facility-Initiated Room Transfer. Resident Name: (R3). Date of written notice given or mailed: 9/27/24 (per phone). Resident Representative Name: FM L (name). This is to notify you of an upcoming move with the facility to another room within the facility. You will be moved from Room Number (room number) on Lane Unit to Room Number (Room Number) on the Way unit. The expected move date is 9/30/24. Family friends are welcome to assist with the move, but staff are available to move belongings as needed. The purpose of the move: Smaller unit to control behaviors affecting others and allow wandering. (Facility Name) understand that moving rooms can be a big change for some individuals, and every care is taken in making the right decision for all of our residents. However, you do have the right to contest this decision and contact your local Ombudsman about this move. The Ombudsman covering this area is: The Ombudsman for [NAME] County is: (Ombudsman C's Name) Email: (Email address) and Phone (Phone Number). On 10/9/24 at 2:30 PM, Surveyor interviewed FM L regarding R3's room transfer. FM L stated the facility was upfront with her and she did not have a concern with the R3's room transfer. On 10/9/24 at 8:35 AM, Surveyor interviewed SW R (Social Worker) regarding the room changes for R1, R2, and R3. SW R stated she called the families on Friday 9/27/24 and told them the residents would be moved on Monday and families needed to come in and sign paperwork. Surveyor asked SW R did the facility give the resident representatives the right to refuse the room transfer. SW R stated it was on the paperwork, Surveyor asked if this was relayed to the families and SW R stated it was. On 10/9/24 at 5:50 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding the room changes. NHA A stated the room changes were necessary as there were gaps in staff supervision of the three residents. NHA A stated the IDT (Interdisciplinary Team) met and decided to make the room changes to lower the ratio from staff to resident and try to protect the residents. Surveyor asked if the families had the right to refuse the room transfer NHA A stated it was written on the form. We told families on Friday afternoon, left papers at the front desk for the families to sign, and moved the residents on Monday.

UNCORRECTED AT VERIFICATION VISIT. See SOD for Event ID #MK7V11 Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents for 4 of 4 residents (R8, R10, R4, and R7) reviewed for falls/accidents and 4 of 4 residents (R1, R6, R2, and R5) reviewed for resident to resident/supervision. R8 required a two-person transfer with a full body lift, a staff member completed the transfer independently and R8 fell out of the lift. Staff did not follow R10's care plan when they transferred R10 to the restroom. Staff did not have foot pedals on R10's chair and Surveyor observed staff pushing R10 down the hall with his left leg dragging under the wheelchair seat. R7 was observed self transferring without gripper socks. R4 was transferred with the incorrect sling. R1 has the potential to be physically aggressive related to dementia and has a recent history of having resident to resident interactions at the facility. R1's care plan has an intervention that R1 is to be monitored every shift. R1 was observed in a common area with another resident and in an activity with other residents with no staff within line of sight or in the immediate area. R2 has the potential to be physically and or verbally aggressive related to dementia. R2's care plan has an intervention that R2 is to be monitored. R2 was observed in a common area with other residents with no staff within line of sight or in the immediate area. R6 has the potential to be physically aggressive related to dementia with a history of harm to others. R6 was observed in a hallway with other residents with no staff within line of sight or in the immediate area. R5 was not monitored per plan of care and was involved in a resident-to-resident incident with R1. This is evidenced by: Facility Falls-Clinical Protocol Policy, dated 2001 with last revision date of [DATE], states in part: As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling .The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk .For an individual who has fallen, staff will attempt to define possible cause within 24 hours of the fall .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling .If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions . The facility policy titled, Lifting Machine, Using a Mechanical, last revised, [DATE], states in part . Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. General Guidelines: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. Steps in the Procedure: 2. Measure the resident for proper sling size and purpose, according to manufacturer's instructions. 13. Lift the resident 2 inches from the surface to check the stability of the attachments, the fit of the sling and the weight distribution. Facility document titled, EZ Way Sling Sizing Chart, states in part . Sling Color Coding System: Gray, Small; Beige, Medium; Burgundy, Large; Green, XL (extra-large). Sling Size and Weight of Patient: Small, ,d+[DATE] lbs (pounds); Medium, ,d+[DATE] lbs; Large, ,d+[DATE] lbs, XL, ,d+[DATE] lbs. Example 1: R8 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Dementia, Aphasia, Seizure Disorder, and Weight Loss. R8 expired on [DATE]. R8's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] indicated R8 had severe cognitive impairment and R8 was dependent on staff for transfers. R8's Activities for Daily Living (ADL) care plan states in part; Goal: I will maintain current level of function in dependence through [DATE]. Interventions: Transfer: I use a medium (Beige colored) EZ Lift Hoyer sling. Progress Note dated [DATE] at 6:59 PM, states in part; Taken to room after supper resident in wheelchair when CNA (Certified Nursing Assistant) went in to room found resident on the floor on right side. Reddened area on right cheek and small bruise forming on left hand by her middle finger. Unwitnessed fall neuros (neurological checks) started. The FRI (Facility Reported Incident) states in part; found on floor at 6:59 PM. Given (resident name) R8 would not be able to move without assistance, an investigation was initiated to determine if misconduct occurred. A statement from CNA E indicated that she went in to put R8 to bed at 6:45 PM and found R8 on the floor. CNA E was interviewed again and reported that she was walking by R8's room on her way to do something else and she saw R8 on the floor. A statement from CNA F was told by CNA E that she thought she set up the Hoyer wrong and she made R8 fall but didn't know and then walked in and found R8 on the floor and was scared it was her fault. A statement from LPN G (Licensed Practical Nurse) resident was in her room after supper. Resident was in her w/c (wheelchair) when CNA went into the room, she found the resident on the floor on her right side. Reenactment of event: (Resident name) R8 is in a modified Broda chair with armrest. R8 lacks the ability to move her body in such a way that she would have been able to fall out of the chair on her own. The reports indicate that R8 was seen on her right side, and the chair would have been blocking the view of her being on the floor if she had fallen out of it. The chair had to be pulled away from view. The Hoyer lift and sling were inspected for rips or malfunction, and none were found. Multiple versions of how the fall occurred were reenacted to recreate how she would have ended up on her right side. All scenarios were ruled out but improper use of the sling hooks. Any other possibility would have resulted in R8 being on her back or the error being too obvious during the slow ascent from the chair. Conclusion: CNA E did not follow facility policy and attempted to transfer R8 without the required second person. CNA E did not properly hook R8 up with the sling when transferring her. R8 fell out of the Hoyer lift sling as a result of CNA E not following facility policy. On [DATE], CNA E's employment was terminated. On [DATE] at 2:40 PM, Surveyor interviewed CNA F regarding R8's fall on [DATE]. CNA F stated she was not working the night of the fall however CNA E told her, a few days after the incident, that she thought she put the Hoyer sling under R8 wrong, and she thought it was her fault that R8 fell . On [DATE] at 2:50 PM, Surveyor interviewed LPN G regarding R8's fall. LPN G stated she was the nurse on the floor that night. LPN G stated there is no way R8 fell out of the chair she had to have fallen from the Hoyer. LPN G stated when she entered the room R8 was lying on her right side with her head facing the window and her legs were toward the bed. The chair was facing the closet on the right side of the room and the lift was pushed into the bathroom with the lift legs facing toward the door. LPN G stated it would be impossible for R8 to have fallen from the chair and be in the position she was found. LPN G stated the sling was all bunched up and, in the chair, and just looked off. LPN G stated it was my conclusion CNA E transferred R8 by herself and R8 fell from the Hoyer. LPN G stated CNA E never admitted to this. Surveyor attempted to contact CNA E; however, CNA E did not return the call. On [DATE] at 9:00 AM, Surveyor interviewed DON B (Director of Nursing) regarding R8's fall. DON B stated R8 was found on the floor and based on the investigation it was concluded CNA E transferred R8 by herself and did not hook up the Hoyer sling correctly causing the fall. DON B stated the conclusion was made based on the position of R8 on the floor. We could not get CNA E to admit to it, but it is believed this was the case. Surveyor asked DON B if CNA E followed R8's care plan, DON B stated No, it would be expected staff follow the care plan and residents should be transferred with two staff when using a Hoyer lift. On [DATE], the facility did complete education on using a Hoyer lift which states in part; 2 staff members must be present. The second person is there to prevent serious injury to the resident. Although the facility started the education, only a small number of staff received this training. Example 2: R10 was admitted to the facility on [DATE] with diagnoses that include Parkinson's with dyskinesia (involuntary movements) and repeated falls. R10's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] indicated R10 has a Brief Interview of Mental Status (BIMS) score of 3 indicating R10 has severe cognitive impairment. Section GG indicates R10 requires substantial assistance with sit to stand, personal hygiene, toilet transfer, and toilet hygiene. R10's Activities of Daily Living (ADL) care plan states in part; I will maintain current level of function through the review date of [DATE]; Interventions: Date initiated: [DATE] and revised [DATE] Transporting: I need to have foot pedals applied when transporting me in my w/c, but I like to self-propel intermittently on the unit. Date Initiated: [DATE] Transfer: I am able to transfer with help of 1 person, gait belt and U-Step walker if allow. I frequently transfer by myself, keep my U-step walker and or wheelchair within hands reach. Tell me to give you a hug and I will help with transfers. On [DATE] at 1:05 PM, Surveyor observed R10 in the dining room, R10 was had his head bent down and appeared to be sleeping in his wheelchair. CNA J (Certified Nursing Assistant) approached R10 and told R10 she was going to take him to his room. CNA J began to transport R10 to his room in his wheelchair without the use of his foot pedals. Surveyor observed R10's left foot dragging under the seat of the wheelchair which was pitching R10 forward in his chair. Surveyor stopped CNA J and pointed out R10's left foot. CNA J stated, come on (resident name) R10 pick up your feet, CNA J moved R10's foot in front of the chair. CNA J continued transporting R10 to his room and once again R10's foot started to drag under the wheelchair seat pitching R10 forward. Surveyor stopped CNA J and pointed out R10's foot. CNA J again stated to R10 to pick up his feet. At no time during the transport from the dining room to R10's room did CNA J stop and get R10's footrest. CNA J pushed R10 in to the bathroom and locked the brakes to the wheelchair. R10 continued to have his head hung down and appeared sleepy. Surveyor observed a gait belt hanging on the bathroom door. CNA K entered the room to assist CNA J with transferring R10 to the toilet R10 became resistive to the transfer and CNA J stated to R10, You know (resident name) if you would assist us, it would not be so hard. CNA J and CNA K lifted R10 under his arms and transferred R10 to the toilet. It should be noted R10's care plan indicates R10 should be transferred with a gait belt and his U-step walker; neither CNA placed a gait belt on R10. Once R10 was standing, R10 was having difficulty sitting and CNA J began using her arms and body weight to push R10 into a seated position on the toilet, R10 continued to resist this attempt placing R10 at greater risk for a fall. Once R10 was seated, CNA K exited the room. When R10 was finished using the restroom CNA J asked R10 to stand and R10 was resistive. CNA J stated to R10, I am going to get the lift, and stated to R10 to quit being so stubborn are you going to sit here all day? CNA I entered R10's room and saw CNA J struggling to transfer R10. CNA I stated let me show you a trick that always works for R10. CNA I got down to R10's level and stated (resident name) can you give me a hug. CNA I reached out her hands to R10 and R10 grabbed her hands began to stand and gave CNA I a hug allowing CNA J to provide personal care and clothing adjustments. CNA I sat R10 into his chair and stated, let's get your foot pedals so we can get you to the recliner safely. Surveyor observed a plastic card just inside the doorway with symbols and text indicating R10 is to transfer with a gait belt, U-step walker, and wheelchair to follow. On [DATE] at 1:20 PM, Surveyor interviewed CNA I regarding transfers for R10. CNA I stated she has found asking R10 to give her a hug is the most effective. Surveyor asked R10 should R10 have a gait belt on with transfers and CNA I stated yes we should have had a gait belt. Surveyor asked about the symbol and text card in R10's room CNA J stated that is an at -a - glance on how the resident (R10) transfers. CNA I stated R10 is not always able to use the walker so using a gait belt and the asking for a hug seems to be the best method. Surveyor asked CNA I if R10 should use the foot rest for transport in the wheelchair and R10 stated yes. On [DATE] at 1:40 PM, Surveyor interviewed CNA J regarding transfers for R10. Surveyor asked CNA J about transporting R10 from the dining room to R10's room Surveyor asked CNA J if she should have used R10's foot rests; CNA J stated yes. Surveyor asked CNA J about the observation of transferring R10 to the toilet and assisting R10 to sit on the toilet. Surveyor asked CNA J how she knows how to transfer a resident. CNA J stated there are cards in the room and the resident's care plan. Surveyor asked CNA J does R10's care plan state to use a gait belt. CNA J stated yes. Surveyor asked CNA J if she used a gait belt and CNA J stated no. Surveyor asked CNA J about assisting R10 to sit on the toilet; Surveyor asked CNA J if pushing on R10 to sit could increase R10's risk of falling CNA J stated yes, R10 was not cooperative today. Surveyor asked if R10's care plan states to use foot pedals for transportation should foot pedals be used when transporting R10? CNA J stated yes and I did not use them. On [DATE] at 9:00 AM, Surveyor interviewed DON B (Director of Nursing) regarding R10's transfers and fall interventions. Surveyor asked DON B if R10 has a care planned intervention and appears sleepy should staff utilize foot rest to transport R10. DON B stated, yes. Surveyor asked DON B if a care plan intervention is to use a gait belt would you expect staff to use a gait belt and DON B stated yes. Surveyor asked DON B about staff assisting R10 to sit on the toilet and DON B stated staff are taught if a resident is resistive to either try another staff member or reapproach. I would have expected the CNA to stop and reapproach. 36192 Example 3: R7 was admitted on [DATE] with diagnosis that include hemiplegia (partial or total paralysis of one side) of right side and epilepsy (seizure disorder.) R7's Care Plan states in part: I have an ADL (activity of daily living) self-care performance deficit r/t (related to) hemiplegia d/t (due to) stroke with right side weakness. date initiated: [DATE] . interventions: Toilet use: I require min. (minimal) assistance by 1 staff for toileting. Use gait belt & stand pivot transfer [[DATE]]. Transfer: I require min. assistance SPT (stand pivot transfer), FWW (front wheeled walker) & gait belt by 1 staff to move between surfaces daily every shift and as necessary .I am unaware of my safety limitations and frequently self-transfer .revision on [DATE]. Focus: I am high risk for falls r/t gait/balance problems, worry about incontinence, unaware of safety d/t confusion/impulsive .revision [DATE] .ensure that I am wearing appropriate footwear non-skid socks or non-skid footwear when ambulating or mobilizing in w/c (wheel chair) . revision on: [DATE] . On [DATE] at 12:47 PM, Surveyor observed R7 to be in her bathroom alone using the restroom. R7 had her wheelchair parked in front of her facing the toilet and her shoes were off her feet and were under her wheelchair. Surveyor left R7's room to stand in the hallway to observe if staff were going to come assist R7. At 12:53 PM, Surveyor heard water running in R7's bathroom and Surveyor went to observe R7. R7 was now sitting in her wheelchair at the sink washing her hands. R7 did not have shoes or gripper socks on at this time, and her shoes were by the toilet. R7 propelled herself in her wheelchair back to her bed. R7 then self- transferred from her wheelchair to her bed. R7's call light was bumped when R7 returned to bed and RN C (Registered Nurse) came into R7's room at 12:56 PM and asked R7 if she needed anything, R7 shook her head no. RN C removed the foot pedals off R7's wheelchair. On [DATE] at 12:58 PM, Surveyor interviewed RN C regarding R7's self-transfer. RN C indicated R7 is not supposed to be up on her own and that even if you go in to offer help, she will still get up on her own. RN C indicated R7 should have gripper socks on. On [DATE] at 2:55 PM, Surveyor observed CNA D (Certified Nursing Assistant) pushing R7 down the hallway to activities in her wheelchair. R7 did not have gripper socks or non-skid footwear on her feet. R7 had Tubi grips on with normal socks over them. Surveyor asked CNA D if R7 had gripper socks on, CNA D stated regular socks. On [DATE] at 2:59 PM, CNA D indicated to Surveyor that she put gripper socks on R7 and that she should have had them on. On [DATE] at 9:00 AM, Surveyor interviewed DON B (Director of Nursing) regarding observations with R7. DON B indicated she would expect R7 to have appropriate footwear or gripper socks on and would expect CNAs to follow the care plan related to nonskid footwear. 39713 Example 4: R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, abnormal weight loss, chronic diastolic (Congestive) heart failure, COPD (Chronic Obstructive Pulmonary Disease), hypertensive heart disease with heart failure, and chronic pain. R4's most recent quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] indicates R4 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R4 requires substantial/maximum assistance with shower/bath, toileting hygiene, upper body dressing, lower body dressing, personal hygiene, roll left to right, lying to sitting, sit to stand, chair/bed-to-chair transfers, and toilet transfers. R4 does not ambulate and is always continent of bowel and bladder. R4's care plan, dated [DATE], states, in part . Focus: I have an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) right tibia fracture. Interventions: Transfer: I require assistance of 2 staff using mechanical lift to transfer from surface to surface. On [DATE] at 12:50 PM, Surveyor observed CNA M (Certified Nursing Assistant) and CNA P transfer R4 from bed to wheelchair with full body lift. R4 had the full body lift sling under her when Surveyor entered R4's room. CNA M hooked the sling to the full body lift as CNA P assisted in guiding R4 to wheelchair. Surveyor had no initial concerns with R4's transfer. Surveyor asked CNA M how staff determine what sling they are to use with each resident. CNA M stated it is based off weight. Surveyor asked CNA M what size sling is used for R4. CNA M stated I believe it is a large sling. Surveyor asked CNA M to show Surveyor how she would know that. CNA M took Surveyor over to R4 and pulled back the label on the sling which indicated the sling used for R4 was a Medium. CNA M stated, this is a medium sling, and we should have been using the large sling based off R4's weight. CNA M pulled out the document titled, EZ Way Sling Sizing Chart to show Surveyor how a sling size is determined. Surveyor asked CNA M how much R4 weighs. CNA M approached RN N to ask what R4's most current weight was. RN N stated, R4's weight on [DATE] was 255.2. Note: According to the facility document titled, EZ Way Sling Sizing Chart a resident weighing 255 lbs. should use a size large sling. The medium sling being used was for weight ,d+[DATE] lbs. R4 exceeds the weight for the medium sling. On [DATE] at 3:05 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how staff determine which sling is to be used with a full body lift. DON B stated it is based off the resident's weight. There is a sheet in a bag on each full body lift that shows the color of the sling based on the residents weight. The facility failed to ensure that staff were using the appropriate sling for lifts based on resident body weight. 29360 Example 5: R1 was admitted on [DATE]. R1's diagnoses include Alzheimer's, Behavioral Disturbances, and glaucoma. R1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] includes, in part, the following: R1 has severe cognitive impairment and can independently ambulate. R1's care plan Focus: I have the potential to be physically aggressive r/t (related to) Dementia, poor impulse control. I may communicate with others by striking out due to not aware how to communicate someone maybe endangering me (if someone is about to run over my feet over, I will draw attention by striking out, no initiation date, includes, in part, the following interventions: Continue monitoring my direction in care I turn around, [sic] Frequent checks. Document in (facility's charting system). If I am agitated, please distract me with an activity i.e., (such as) offer me a washcloth to wipe down railings in hallways. Monitor every shift. Document observed behavior and attempted interventions in behavior log. Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of me posing danger to self and others. My triggers for physical aggression are frustration or inability to communicate safely. My behaviors are (sic) de-escalated by walking outside, doing meaningful activities, such as cleaning, wiping hand rails, folding clothes, helping staff. I feel like I work here. Request I stop pushing residents in their wheelchairs and redirect me to another activity . When I become agitated: Intervene before agitation escalates. Guide me away from source of distress; Engage me calmly in conversation; if my response is aggressive staff to walk calmly away and approach me later. When (R1) starts grabbing for others; we will provide something for her to do with her hands i.e. Hold our hands, stuffed animal, baby. The facility's Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report, dated [DATE], 10:00 AM, includes, in part, the following: (R2) was in her wheelchair sitting in the doorway between Lane and View unit. Staff member was walking with (R1) through the doorway. Staff member positioned herself between the residents as they walked through. (R1) stopped to fix her shoe and (R2) reached around a staff member and hit (R1) on the face and across the shoulder. Neither (R2) or (R1) due to cognition were able to describe what happened to instigate the resident-to-resident altercation. The facility's Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report, dated [DATE], 1:36 PM, includes, in part, the following: On [DATE] (CNA T) (Certified Nursing Assistant) was exiting a resident's room down the hall. (CNA T) saw (R1) trying to push (R2) down the hallway. (CNA T) asked (R1) to let go of the wheelchair, when she let go, she grabbed the railing with her right hand and grabbed (R2's) right arm with her left hand for stabilizations. (R2) started yelling and hit (R1) 3 times on left arm. (CNA T) separated residents immediately and (R2) was put in line of sight. Neither (R2) or (R1) recall the incident. Both denied pain, appeared calm sitting in the lounge area and no evidence of bruising at this time. The facility's Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report, dated [DATE], 4:00 PM, includes, in part, the following: (R12) reported to AA Q (Activity Aide) that (R1) pinched her in the left upper arm while in an activity. (R1) was seated next to (R12) at the activity and when AA Q turned around (R12) said (R1) pinched her. When AA Q turned back around (R1) was standing walking. It is believed that (R1) grabbed (R12's) arm when standing up possibly to stabilize herself. On [DATE] at 1:38 PM, CNA P (Certified Nursing Assistant) accompanied R1, who ambulated independently, to an activity in a common room at the end of Hill View unit. CNA P left R1 sitting at the table with other residents within reach. AA Q was in the room. 1:47 PM, AA Q left the room. R1 was left unsupervised with a resident on either side of her, sitting at the table within reach. 1:52 PM, AA Q returned to the room. On [DATE] at 3:20 PM, R1 was observed sitting in a common area in the middle of the units with another resident within reach of R1. There were no staff within line of sight or in the immediate area to monitor R1. On [DATE] at 3:30 PM, Surveyor interviewed DT R (Dementia Technician). DT R stated that R1 paces and can get agitated and weepy. When R1 shows behaviors of being agitated staff have to stay with R1. DT R stated she is aware of this happening two to three times a week. DT R states as long as staff know where R1 is staff do not have to be with her unless she is agitated. On [DATE] at 3:50 PM, Surveyor interviewed RN S (Registered Nurse). RN S stated R1 does not have a set time or a specific thing that sets off R1's agitation. Staff keep an eye on her and report to me when she becomes agitated. Example 6: R2 was admitted to the facility on [DATE]. R2's diagnosis include dementia, depression, and chronic pain. R2's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] includes, in part, the following: R2 has severe cognitive impairment and wanders. R2's Care Plan Focus: I have the potential to be physically and/or verbally aggressive r/t (related to) Dementia, Date Initiated: [DATE], Revised on: [DATE], includes, in part, the following interventions: Document observed behavior and attempted interventions. Monitor/document/report PRN (As Needed) any s/sx (Signs/Symptoms) of me posing danger to self and others. When I become agitated: Intervene before agitation escalates, guide me away from source of distress, engage me calmly in conversation, if my response is aggressive, staff to walk calmly away while continuing to ensure safety of myself and others, and approach me later. When resident showing signs of increased agitation including, but not limited to, elevated tone and volume of voice, negative vocalization, speech regarding her farm or money, violent speech, pacing, or clenching fists, nurse will implement frequent checks to ensure resident and other residents' safety. On [DATE] at 9:05 AM, R2 was observed in her wheelchair, in an activity on the unit, sitting within arm's reach of other residents. Activity staff were in and out of the room, leaving R2 unmonitored. On [DATE] at 6:30 AM, R2 was observed sitting in her wheelchair, other residents were in the area, no staff were within eyesight to monitor R2. Example 7: R6 was admitted [DATE]. R6's diagnosis include Alzheimer's, delusional disorder, depression, and chronic pain. R8's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE], includes, in part, the following: R6 has severe cognitive impairment. R6's Care Plan Focus: I have the potential to be physically aggressive (hitting, pinching, grabbing, running into staff with my wheelchair) r/t (related to) Dementia. History of harm to others. Poor impulse control. Date Initiated: [DATE], Revision on [DATE], includes, in part, the following interventions: When (R6) starts grabbing for others, we will provide something for her to do with her hands is hold our hands, stuffed animal, baby. Date initiated: [DATE]. When I appear distressed ex (example) Self propelling in the hallways steadily or reaching out to others, the floor nurse will assign a staff member to stay with her and keep others out of the way. Date initiated [DATE], Revision on: [DATE]. When I become agitated: Intervene before agitation escalates. Guide me away from source of distress. Engage me calmly in conversation. Date Initiated: [DATE], Revision on [DATE]. When I have increased anxiety and agitation, please try to redirect me to my room so I can lay down for a little while then reassess anxiety/agitation after that. Date Initiated: [DATE], Revision on: [DATE]. The facility's Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report, dated [DATE], 4:05 PM includes, in part, the following: (R6) grabbed (R1's) sleeve. Staff intervened and asked (R6) to let go of (R1's) sleeve. When (R6) let go; (R1) lost her balance and went down on left knee. (R6) will be checked by staff every 15 minutes to ensure that she is not near other residents at this time. The facility's Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report, dated [DATE], 11:57 AM, includes, in part, the following: (R6) was reaching for (R1) as she walked by. CNA (Certified Nursing Assistant) was there to intervene and stop (R6) before could make contact with (R1). CNA was thinking it was resolved. (R1) then turned and grabbed (R6's) shirt and scratched her on the left shoulder. On [DATE] at 4:30 PM, R6 was observed sitting up in her wheelchair in the hallway with other residents near R6. There were no staff in the hallway to monitor R6. Example 8: R5 was admitted on [DATE]. R5's diagnosis include dementia, anxiety, and depression. R5's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] includes, in part, the following: R5 has severe cognitive impairment, physical behaviors towards others and verbal behaviors towards others. R5's Care Plan Focus: I have the potential to be physically aggressive (hitting others) r/t (related to) Dementia, Poor impulse control, Date Initiated: [DATE], includes, in part, the following interventions: Monitor each shift and as needed. Document observed behavior and attempted interventions in behavior log. Monitor/document/report PRN (as needed) any s/sx of me posing danger to self and others. If I am posing a threat to other residents have a staff member assigned to monitor or spend time with me. Resident has shown increased confusion and wandering into peers rooms, particularly after experiencing a sleepless night, absence seizure, pain that she is unable to express, or concerns with constipation. When I become agitated assign a staff member to stay with resident and intervene before agitation escalates. Guide me away from source of distress. Engage me calmly in conversation. If my response is aggressive, staff to walk calmly away, and approach me later. Initiating playing music will sooth me at times. Date initiated: [DATE]. Revision on: [DATE]. The facility's Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report, dated [DATE], includes, in part, the following: Date occurred: [DATE]. Time occurred: 12:45 PM. Brief Summary of Incident: (R1) were (sic) passing each other in the hallway when both (R1 and R5) started to slap each other and (R1) pull (sic) (R5's) hair. Staff intervened immediately and each resident was taken to their home area. Both (R1 and R5) have dementia and severe impairment. Both residents were assessed for injury and psychosocial effects. Neither resident had any indication of injury or effect, but they will continue to receive assessments for the next 7 days. Both residents will remain with staff on their resp [TRUNCATED]

Based on interview and record review, the facility failed to ensure residents receive the care and treatment in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 of 2 residents reviewed (R8 and R4). R8 did not have neurological checks completed after a fall per facility protocol. R4 was admitted with orders to weigh daily and update the Physician with a weight increase or decrease by 3 lbs. (pounds) in a day or 5 lbs. in a week. R4's weights were not completed daily, and the physician was not always informed when weights fell outside the given parameters. This is evidenced by: The facility has an Unwitnessed Fall Checklist, undated, which state in part; if resident is unable to tell you if they hit their head, assume they did and do neuro (Neurological) checks with vital signs. Neuro checks are to be completed in PCC (Point Click Care/Electronic Health Record) under the assessment tab. Vital signs/Neuro Checks at time of fall and fifteen minutes after fall, 1 hour after fall and each shift for 24 hours after fall for 72 hours. Facility policy titled, Weight and Measuring the Resident, last reviewed, 3/2011, states in part . Purpose: The purposes of this procedure are to determine the resident's weight and height, to provide a baseline and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident. Preparation: 5. When weighing the resident, the following guidelines will promote accurate weight assessment across time: a. If practical, weigh at the same time of day each day. b. If the resident's condition permits, use the same scale for weighing the resident each time. Interact Version 4.5 Tool for Change in Condition: When to report to the MD/NP/PA (Medical Doctor/Nurse Practitioner/Physician Assistant), states in part . Immediate Notification: Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and: A Marked Change (i.e., more severe) in relation to usual symptoms and signs, or Unrelieved by measures already prescribed. Weight Loss: Report Immediately: 5% (percent) or more within 30 days. Weight Gain: > (greater than) 5 lbs (pounds) in one week in resident with CHF (congestive heart failure), chronic renal failure, other volume overload state. Example 1 R8 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Dementia, Aphasia, Seizure Disorder and Weight Loss. R8's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/16/24 indicated R8 had severe cognitive impairment and R8 was dependent on staff for transfers. R8's Activities for Daily Living (ADL) care plan, states in part; Goal: I will maintain current level of function in dependence through 8/18/24. Interventions: Transfer: I use a medium (Beige colored) EZ Lift Hoyer sling. Progress Note dated 7/20/24 at 6:59 PM states in part; Taken to room after supper resident in wheelchair when CNA (Certified Nursing Assistant) went in to room found resident on the floor on right side. Reddened area on right cheek and small bruise forming on left hand by her middle finger. Unwitnessed fall neuros (Neurological Checks) started. R8 has the following neurological checks noted: 7/20/24 at 7:18 PM pupils were equal and reactive to light indicating neurological functions intact. 7/20/24 at 7:35 PM pupils were equal and reactive to light indicating neurological functions intact. Of note, the next set of Neuro checks should have been around 8:35 PM. 7/20/24 at 9:43 PM pupils were equal and reactive to light indicating neurological functions intact. 7/21/24 at 6:30 AM pupils were equal and reactive to light indicating neurological functions intact. 7/21/24 at 10:54 pupils were equal and reactive to light indicating neurological functions intact. There were no further neurological checks. R8 should have had neurological checks on 7/22/24 and again on 7/23/24 per facility protocol. On 9/17/24 at 9:00 AM, Surveyor interviewed DON B (Director of Nursing) regarding R8's neuros checks and facility protocol. DON B stated she would review the record and get back to Surveyor. On 9/17/24 at 10:10 AM, DON B stated there were no further neuro checks for R8 and the facility did not follow their protocol. 39713 Example 2 R4 was admitted to the facility on [DATE], with diagnoses, including, but not limited to, abnormal weight loss, chronic diastolic (congestive) heart failure, COPD (chronic obstructive pulmonary disease), hypertensive heart disease with heart failure, and chronic pain. R4's most recent quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/10/24 indicates R4 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R4's care plan states in part . Focus: I have Congestive Heart Failure Interventions: Weight daily. Date Initiated: 7/10/24. Focus: I have coronary artery disease (CAD) r/t (related to) lifestyle choices, hx. (history) of smoking. Interventions: Weight daily. Date Initiated: 6/06/24. Focus: I have potential fluid volume overload r/t CHF. Interventions: Weight daily. Notify MD (Medical Doctor), RD (Registered Dietician) of sudden wt. (weight) changes. R4's physician orders, states in part . Weigh daily one time a day for CHF (Congestive Heart Failure), CHF patient, notify provider if weight gain > (greater) 3 lbs. (pounds) in one day, >5 lbs. in one week, or increased leg pain/swelling or SOB (Shortness of Breath); AND notify monthly if weight loss/gain is >5% (percent) in one month, >7% in three months, >10% in 6 months. R4's weights are documented from 7/6/24 until present as follows: 7/06/24 - 251.8 lbs. 7/09/24 - 248.6 lbs. 7/13/24 - 249.6 lbs. 7/21/24 - 241.6 lbs. 7/24/24 - 238.6 lbs. 7/26/24 - 237.6 lbs. 8/12/24 - 246.2 lbs. (increase of 8.6 lbs., NP (Nurse Practitioner) updated 8/13/24 of weight increase) 8/19/24 - 243.4 lbs. 8/22/24 - 237.1 lbs. 8/24/24 - 237.5 lbs. 8/26/24 - 246.2 lbs. (increase of 8.7 lbs., NP updated on weight increase) 8/29/24 - 251.6 lbs. (increase of 5.4 lbs., NP updated on weight increase) 9/02/24 - 248 lbs. 9/07/24 - 248.3 lbs. 9/10/24 - 257.6 lbs. (increase of 9.3 lbs., NP updated on weight increase) 9/11/24 - 257.6 lbs. 9/12/24 - 255.8 lbs. 9/13/24 - 255.2 lbs. 9/16/24 - 257.4 lbs. Note: Weights were not obtained as ordered on the following dates, 7/04, 7/08, 7/10, 7/11, 7/12, 7/14, 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, 7/22, 7/23, 7/25, 7/27, 7/28, 7/29, 7/30, 7/31, 8/01, 8/02, 8/03, 8/04, 8/05, 8/06, 8/07, 8/08, 8/09, 8/10, 8/11, 8/13, 8/14, 8/15, 8/16, 8/17, 8/18, 8/21, 8/23, 8/25, 8/27, 8/28, 8/30, 8/31, 9/01, 9/03, 9/04, 9/05, 9/06, 9/08, 9/09, 9/14, and 9/15. On 9/16/24 at 3:05 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what standard of practice the facility uses. DON B stated, AMDA (The American Medical Directors Association) guidelines. Surveyor asked DON B the facility procedure for obtaining weights. A weight should be obtained weekly on admission for 4 weeks, then monthly. If there is a physician's order for something different, that should be followed weights should be done daily if they are ordered that way. If a resident refuses the staff will try again later or wait until the next day. Staff should be documenting any resident's refusal to have weight obtained. Refusals should also be reported to the nurse. CNA's (Certified Nursing Assistants) put weights in the computer system. Surveyor asked DON B what happens if weight is off or is significantly higher or lower. The computer charting system will trigger the nurse if weight is off and the floor nurses should be reviewing daily weights. On 9/16/24 at 3:45 PM, Surveyor interviewed CNA L and CNA O. Surveyor asked CNA L and CNA O about the facility process for obtaining weights. CNA L stated resident weights are obtained on bath days. The nurse will let us know any weights and vital signs that need to be taken. Then we either write them down and put them in the computer or give them to the nurse. CNA O indicated she would follow the same process as what CNA L had stated. On 9/17/24 at 6:30 AM, Surveyor interviewed CNA M. Surveyor asked CNA M the facility process for obtaining resident weights. CNA M stated, the nurse tells us who is a weight that day. We obtain the weight then give the weight to the nurse and chart it in the medical record. Surveyor asked CNA M if there is anything that triggers to let them know that the weight is off. CNA M stated, it does not trigger us that I have noticed in the CNA charting. The nurse should look and see if there is an issue with the weight that was obtained. Surveyor asked CNA M how they obtain a re-weight. CNA M stated if a re-weight is needed the nurse lets us know. On 9/17/24 at 6:35 AM, Surveyor interviewed RN N (Registered Nurse). Surveyor asked RN N facility process for obtaining weights. RN N stated, we do our weights weekly on admit for 1 month then monthly, if a resident has CHF, they are daily weights. If a resident gains >3 lbs. in a day or >5 lbs. in a week we would need to update the physician. Staff would also update the physician if gain of 5% in a month, 7% in 3 months, and/or 10% in 6 months. RN N stated the CNA's would update the nurse if R4 or another resident is still refusing. R4 refuses a lot due to pain. Surveyor asked RN N if she updates the physician when R4 refuses. RN N stated, I don't update every time R4 refuses. R4 is doing better now and back in therapy. The facility failed to obtain daily weights for R4 as ordered and update the physician when daily weights could not be obtained.

Based on observation, interview, and record review, the facility did not ensure hand hygiene and infection control practices were performed to prevent the spread of infection for 1 of 4 residents (R11) observed for hand hygiene and infection control opportunities. Staff were observed not completing hand hygiene per standards of practice, placing dirty washcloths in the wash basin, placing dirty washcloths on the bedside table, not disinfecting the bedside table or mechanical lift. This is evidence by: The facility policy titled Handwashing/Hygiene dated revised 8/2019 states in part; the facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. 3. Hand hygiene products and supplies shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene polices. 6. Wash hands with soap and water for the following situations: a. When hands are visibly soiled. 7. Use an alcohol-based hand rub containing at least 62 % alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a. before and after coming on duty. b. before and after direct contact with residents. h. before moving from a contaminated body site to a clean body site during resident care. i. after contact with residents intact skin j. after contact with blood or bodily fluids k. after handling used dressings or contaminated equipment. l. after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. m. after removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. Applying and removing gloves: 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. R11 was admitted to the facility on [DATE] with diagnoses including hemiplegia secondary to Cerebrovascular Accident (paralysis after stroke). R11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/3/24 indicates R11 is dependent on staff for care and transfers. On 9/16/24 at 10:30 AM, Surveyor observed personal care being provided to R11 by DON B (Director of Nursing) and CNA H (Certified Nursing Assistant). CNA H entered the room and did not perform Hand Hygiene (H/H) CNA H applied gloves and began performing peri care. R11 stated to CNA H, I am wet. CNA H used a clean washcloth from the wash basin and began providing peri care with soap and water. Once CNA H was completed peri care washing CNA H did not remove her gloves or perform H/H. With the same dirty gloves CNA H reached into the clean water basin to grab a washcloth to rinse R11, CNA H rinsed R11 with the washcloth and laid the wash cloth on the bedside stand. CNA H took a dry towel and patted R11 dry. DON B and CNA H rolled R11 on her side and R11 had visible stool on her bottom. CNA H with the same dirty gloves went into the wash basin and washed R11's bottom and removed the stool. CNA H threw the dirty wash cloth into the clean basin and with the same gloves took a washcloth out of now the soiled basin to rinse R11's bottom. CNA H at no time removed her gloves or performed H/H. CNA H with the same gloves grabbed a tube of barrier cream and placed on R11's bottom. CNA H then removed her right glove although did not perform H/H. DON B requested a clean washcloth for R11, and CNA H entered the bathroom did not remove her soiled glove or perform H/H wet a wash cloth, wrung the washcloth out and handed the washcloth to DON B and DON B used the wash cloth to wash R11's back. CNA H and DON B transferred R11 to her wheel chair. CNA H continued to have the soiled glove on her left hand. Once R11 was in the chair CNA H went to R11's bedside stand and grabbed R11's brush and began to brush R11's hair. CNA H was brushing R11's hair with her right hand and using her soiled, gloved left hand to run her fingers through R11's hair. CNA H put the brush back on the bedside stand removed her glove did not perform H/H. CNA H removed the wash basin helped R11 get settled into her chair and exited the room without performing H/H. CNA H did not disinfect the bedside stand despite having soiled washcloths on the bedside stand and did not disinfect the lift after use. On 9/16/24 at 10:55 AM Surveyor spoke with CNA H regarding infection control practices and hand hygiene. Surveyor asked CNA H when she should wash her hands. CNA H stated when entering a room, when visibly soiled, after removing gloves and when ever dirty. Surveyor asked CNA H if she washed her hands upon entering R11's room CNA H stated she did not. Surveyor asked CNA H if she removed her gloves or performed H/H after providing peri care CNA H stated she did not. Surveyor asked CNA H if she disinfected the bedside stand of lift after use CNA H stated she did not and she should have. On 9/17/24 at 9:00 AM Surveyor interviewed DON B regarding the H/H opportunities with CNA H. DON B stated she did realize CNA H placed a dirty washcloth in the wash basin and asked CNA H to get a clean washcloth. DON B did not realize there were missed H/H opportunities. Surveyor shared the observations made and DON B stated she would have expected H/H when going from dirty to clean and when removing gloves or whenever soiled. DON B stated she would expect the bedside table and lift to be disinfected after use.

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 1 residents reviewed for elopement (R58), 6 of 17 sampled residents (R2, R40, R59, R1, R66, R48) and 6 of 13 supplemental residents (R10, R31, R39, R45, R35, R50) reviewed for wandering, and 1 of 13 supplemental residents reviewed for accidents (R6). R58 has a history of multiple falls, exit seeking behaviors, and elopement. Facility staff did not provide adequate supervision to prevent elopement when R58 was exit seeking. R58 exited through an alarmed door, took his wheelchair down a stairwell, and was found at the bottom of a flight of stairs. Although the door alarm activated and would have sounded for 15 seconds before the stairwell door opened, staff did not respond because there was no staff in the immediate area. When a staff person heard the alarm, the alert board, which indicates to staff which door was alarming, was not functioning, leading to a delay in locating R58. The facility's failure to provide adequate supervision and maintain a functioning alarm system created a finding of Immediate Jeopardy that began on 5/13/2024. Surveyor notified the NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the Immediate Jeopardy on 6/27/2024 at 2:25 PM. The Immediate Jeopardy was removed on 6/27/24; however, the deficient practice continues at a scope/severity of an E (potential for minimal harm/pattern) as evidenced by the following examples: R51 wanders into other resident rooms. R1, R66, R39, R45, and R35 stated they did not want R51 in their room. The facility provided them with stop signs across their doors, but did not care plan these, nor did they monitor them for effectiveness. R1 stated that she was afraid of R51. R48, who is not cognitively intact and unable to voice concerns, was not offered a stop sign or other protections from R51 entering her room. R31, R39, R10, and R40 voiced concerns at a Resident Council meeting regarding wandering residents entering their room uninvited. R2, R50, and R59 voiced concerns during individual interviews regarding wandering residents entering their room uninvited. Staff reported they were aware of concerns voiced by R2, R50, R59, R40, R10, R39, and R31 and aware the interventions in place were not working to keep uninvited wandering residents out of their rooms. Staff did not place foot pedals on R6's wheelchair causing R6's leg to get caught under the wheelchair. This is evidenced by: Facility Falls-Clinical Protocol Policy, dated 2001 with last revision date of September 2012, states in part: As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling .The staff will document risk factors for falling in the resident's record and discuss the resident's fall risk .For an individual who has fallen, staff will attempt to define possible cause within 24 hours of the fall .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling .If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling .If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions . Facility Wandering and Elopements Policy, dated 2001 with last revision date of March 2019, states in part: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety . R58 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease, adjustment disorder with anxiety, chronic pain, other lack of coordination, repeated falls, vascular dementia unspecified. R58's most recent MDS (Minimum Data Set) dated 3/5/2024 states that R58 has a BIMS (Brief Interview of Mental Status) of 8/15 indicating that R58 has moderate cognitive impairment. R58's baseline care plan dated 5/30/2023 states in part, . I am an elopement risk/wanderer related to disoriented to place, impaired safety awareness. Distract me from wandering into other resident rooms by offering pleasant diversions, structured activities, food, conversation, television, book. I prefer country music, working on a horse ranch . I have limited physical ability related to Alzheimer's and frequent falls. I am able to move about the unit with an assistance of 1 person in my wheelchair. I can propel by wheelchair independently but do need supervision to prevent exit seeking. R58 had a wander guard bracelet placed on 6/23/2023. R58's care plan was updated on 8/14/2023 to include the intervention: When wandering and busy on the unit, keep me active and in dayroom for closer supervision to prevent attempts of self-transfers. R58's progress notes list the following: 1/2/2024 at 9:04 PM: Resident busy this pm, exit seeking. Unable to redirect with conversation, 1:1, food, toileting, or snacks. Resident did eventually settle down and is sitting in wheelchair, no distress observed. Resident was offered a non-alcoholic beer and resident appeared to content with that and a tractor book, 1:1 with staff. 1/3/2024 at 07:21 AM: Resident did not sleep this NOC (overnight) shift. Resident was adamant to go pick up [NAME]. Resident was exit seeking from 1:00 AM to 4:30 AM. 1/6/2024 at 9:27 PM: Resident busy this pm, intermittent exit seeking, redirectable this pm. Compliant with medications. R58's care plan was updated on 1/30/2024 to include the intervention: Do not leave resident alone if he verbalizes the need to move. R58's progress notes list the following: R58's care plan was updated on 3/6/2024 to include the intervention: Distract me from wandering into other resident rooms by offering pleasant diversions, structured activities, food, conversation, television, book. I prefer country music, working on a horse ranch. R58's progress notes list the following: 3/7/2024 at 7:22 PM: Exit seeking, just going to the exits not through them or setting off alarms at this time. Resident is re directable at this time. No behaviors observed. R58's Elopement assessment dated [DATE] with score 4, meaning at risk for elopement is as follows: History of elopement while at home: Yes. History of attempting to leave the facility without informing staff: Yes. Verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door: Yes. Wanders: Yes. Wandering behavior, a pattern or goal-directed: Yes. Wanders aimlessly or non-goal-directed: No. Wandering behavior likely to affect the safety or well-being of self/others: No. Wandering behavior likely to affect the privacy of others: Yes. Recently admitted or readmitted (within the past 30 days) and has not accepted the situation: No. R58's Wandering assessment dated [DATE] scored him at an 11, meaning High risk to Wander. R58's progress notes list the following: 4/14/2024 at 10:31 PM: Resident was actively exit seeking this pm, not going through the doors, but setting the alarms off and when staff attempted to redirect resident became agitated and attempted to swing hands at staff. No contact with staff made. Resident was re-directed finally with snacks and activities. 4/22/2024 at 2:12 PM: Epic (electronic record system) sent to Doctor of Nursing Practice (DNP) notifying of resident's unwitnessed fall this morning at 7:25 AM Resident has been awake for over 24 hours straight and is not redirectable. Resident found sitting on floor in his room with many of his clothes packed since he is leaving. No injuries noted. Vital signs stable and neurological checks normal. R58's care plan was updated on 4/23/2024 to include the intervention: Provide structured activities: toileting, reorientation strategies including signs, pictures and memory boxes. R58's progress notes list the following: 4/26/2024 at 9:23 PM: Resident exit seeking and looking for my car. Staff attempted to redirect resident; resident became agitated with staff, swinging arms at staff. Resident was redirected with balloon game briefly. Resident is watching a movie and 1:1 with Resident Assistant (RA) at this time. 5/4/2024 at 8:41 PM: Resident exit seeking after supper. Needed frequent redirection. I have livestock to care for. RA sitting with resident part of shift attempting to redirect him. 5/13/2024 at 6:45 PM: Elopement attempt made by resident; alarms sounded. Staff reported a 911 situation, resident had gone through door and down one flight of stairs in wheelchair; chair was on stairway tilted, resident was standing at bottom of landing holding onto both railings; staff assisted resident to chair on landing. Resident description: adamant several times that he did not fall, did not hit anything; denies pain. Immediate action taken: Assisted with 3 staff to bottom of 2nd stairs, then to wheelchair and back to unit via elevator; 1:1 staff assistance at this time, administrator Power of Attorney (POA) and Director of Nursing (DON) updated. Predisposing factors: Door alarm sounding light up alert board not functioning, staff found resident at bottom of 1st stairwell, standing on landing with wheelchair on stairs behind him. (It is important to note: There is a kiosk at both ends of the hallway which displays call lights and door alarms that have been activated. There are doors at both ends of the hallway leading to the stairs. The door is alarmed, but it does not have a wander guard unit on it. When the door is pressed an alarm will sound and then the after 15 seconds the door releases and opens. This means the alarm sounded for 15 seconds before the stairwell door opened, during which time staff did not respond.) R58 had a new wander guard placed on 5/27/2024 with expiration date of 3/19/2025. R58's care plan was updated on 5/27/2024 to include the following: Goal: I will not leave facility unattended through the review date. Interventions: My safety will be maintained through the review date. I will demonstrate happiness with daily routine through the review date. If I am talking about leaving the building. Try the following interventions, in part: Explain I do not have to work today. Try calling significant other .line of sight staff attendance when exit seeking .Provide structured activities: toileting, reorientation strategies including signs, pictures and memory boxes. R58's progress notes list the following: On 6/24/24 from 4:03PM-4:05 PM, Surveyors observed R58 by an exit door, running his hand along it, running his hand along the wall, and trying to stand up independently. R58 was stating he had to get out of here and had to get to his truck. Surveyors tried to interview resident about waiting for a staff member to help. Surveyor looked down hallway to find a staff member but did not see one. Resident insisted, stating he has his truck parked outside and needed to get home. Life Enrichment Aide came down the length of the hallway and intervened with conversation and they went together to the center of the hallway. On 6/26/2024 at 08:52 AM, Surveyors observed R58 on the end of the hall in dining room sitting in his wheelchair at the table. There were no staff present and he could not be seen coming down the hallway. Surveyors greeted resident and looked his wheelchair over for anti-tip bars. On 6/26/2024 at 2:38 PM, RN K (Registered Nurse) indicated R58 was known to exit seek and try to self-transfer. She stated on 5/13/2024 there were 2 CNAs (Certified Nursing Assistant) in the two farthest rooms down the hall providing cares while the nurse on the unit went down to the kitchen to take the dirty dishes, leaving R58 unsupervised. One CNA came out of the room and heard the door alarm. When she looked at the lighted alarm system it was blank. This means the door that was activated did not read across the lighted board. The CNA went to the center of the two halls and listened where the sound was coming from. She went toward the sound. CNA found the R58 and his wheelchair at the bottom of the flight of stairs. RN K indicated staff are to have R58 in line of sight so they can supervise him when he is out of his room. RN K indicated resident still talks about leaving and still tries to self-transfer. On 6/26/2024 at 2:44 PM, CNA L indicated that from time-to-time R58 has exit seeking behaviors. On 5/13/2024 at approximately 3:30 PM, R58 was exhibiting exit seeking behaviors, but he calmed down and ate supper. CNA L stated she and her partner thought the nurse was supervising him, but she left the unit to take down the dirty dishes and did not communicate this. CNA L indicated staff were to supervise him and she thinks this means he should have been in a staff member's line of sight. CNA L stated since the incident R58 still tries to self-transfer and still tries to elope. CNA L stated staff are to keep him in the line of sight, but they can't always if they are in a room. On 6/26/2024 at 3:40 PM, LPN J (Licensed Practical Nurse) indicated resident R58 is to be in line of sight of staff at all times, but no one staff is assigned to him. They all just try to keep him in the common areas. On 6/26/2024 3:59 PM, CNA G indicated she is supposed to make sure R58 is always within where staff can see him, but no one staff is specifically assigned to supervise him. CNA G indicated she works night shift, and they can't always keep an eye on him because they have others to attend to. Sometimes they have an RA who will sit with him and do activities. On 6/26/2024 at 4:04 PM, RA H indicated she tries to meet R58 where he is and talk about things that are important to him like farming, tractors, and milking cows. RA H indicated resident is to be supervised. RA H indicated to supervise you have to have your eyes on him and be near him to make sure he is safe. On 6/26/2024 at 4:10 PM, Life Enrichment Aide I indicated on Monday 6/24/2024 around 4:00 PM she was gathering residents for an activity when she saw R58 near an exit door on the opposite end of the hallway from where he lives. Resident was trying to self-transfer and was talking about leaving, finding his truck, and going home. Life Enrichment Aide I stated she knows he is supposed to be supervised or in the line of sight of someone, but it was not her and she did not see staff around. Life Enrichment Aide I indicated she intervened, so he did not attempt to go out the exit door or fall. On 6/26/2024 at 5:07 PM, NHA A (Nursing Home Administrator) stated on 5/13/2024 they were changing their call light system out. NHA A indicated the lighted alert board malfunctioned, but the door functioned appropriately. NHA A indicated staff were to supervise R58 and didn't, they knew he was exit-seeking, and the plan was to have someone with him. The nurse was supposed to be in the lobby, and she went to the kitchen to drop off dishes and came back up, leaving R58 unattended. NHA A stated it is her expectation that there would always be someone on the floor with R58 in their line of sight. NHA A indicated since the event, R58 continues to exit seek, talk about leaving, talk about getting to his truck, and tries to self-transfer. NHA A indicated R58 is to be in the line of sight of a staff member but no one staff is specifically assigned to this task. The facility's failure to adequately supervise a resident who had been identified as a high risk for elopement and had a known history of exit-seeking behaviors created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 6/27/24 when they completed the following: - On 6/26/24, staff in nursing, life enrichment, housekeeping, and maintenance were educated regarding the intervention to have line of sight supervision when resident indicates that he is exit-seeking and the need to call maintenance immediately if there are issues identified with the Wander Guard or call light system prior to their next shift. -On 6/26/24, all resident care plans were reviewed for individuals with identified wandering/elopement concerns. All elopement assessments are up to date as are all of the assessments for new residents that would have put them into this category. -On 6/26/24, the interventions were reviewed for adequacy to meet safety needs and to determine if all increased supervision needs were being met. No other care plans were identified where increased supervision was listed as an intervention. -On 6/26/24, the policy for managing care plan interventions regarding wandering and exit-seeking was changed to include monthly reviews of all plans, or sooner if elopement occurs, by the clinical team which includes DON, nursing management, and social services. -As of 6/26/24, daily audits of the delayed egress door system functionality were implemented. -As of 6/26/24, the procedure for notifying maintenance regarding the failure of the elopement prevention system has been updated to include notification immediately to prevent elopement. On 6/27/24, education was provided on the facility has an elopement prevention program listing the names and pictures of the individuals who are high risk for elopement on each unit. Staff have been educated/reeducated on the program and their roles. -DON or DON designee will audit the care plan interventions for proper practice and implementation on a daily basis for one week, then weekly for a month, then monthly for three months, then quarterly. -Action and reeducation will take place promptly upon discovery if it is discovered that interventions are not being properly employed. -Maintenance supervisor will review the WorxHub system for work orders regarding the elopement prevention system that are not being reported promptly on a daily basis for one week, then weekly for one month, and monthly for three months, then quarterly. Action and education will take place promptly if policy is not followed. -Results will be presented to QAPI. 36253 Example 2: R51 was admitted to the facility on [DATE] with the following diagnoses of Alzheimer's disease (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), unspecified, delusional disorders (a type of psychotic disorder that is an unshakable belief in something that's untrue), major depressive disorder (a severe and persistent low mood, profound sadness, or a sense of despair), generalized anxiety disorder (extremely worried or nervous more frequently even when there is little or no reason to worry about them), and adjustment disorder (an emotional or behavioral reaction to a stressful event or change in a person's life) with mixed anxiety and depressed mood. R51's most recent MDS (Minimum Data Set) dated 6/11/24, states that R51 has a BIMS (Brief Interview of Mental Status) score was not conducted indicating severe cognition and R51 is rarely or never understood. R51's plan of care, states in part . Focus: I have the potential to be physically aggressive (hitting, pinching, grabbing, running into staff with my wheelchair) r/t (related to) Dementia, History of harm to others, Poor impulse control, Date initiated on: 2/28/24, Revision on: 3/6/24. Goal: I will not harm self or others through the review date. Interventions: . Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of me posing danger to self and others. Date initiated: 2/28/24 . When I become agitated: Intervene before agitation escalates; Guide me away from source of distress; Engage me calmly in conversation; If my response is aggressive, staff to walk calmly away, and approach me later. Date Initiated: 2/28/24. When I have increased anxiety and agitation, please try to redirect me to my room so I can lay down for a little while then reassess anxiety/agitation after that. Date Initiated: 3/6/24 . Focus: I am a wanderer; I wander aimlessly and into other residents rooms and will sometimes lay down in their beds r/t Alzheimer's disease, unaware of safety needs. Date Initiated: 3/22/24 Goal: My safety and other residents safety will be maintained through the review date. Date Initiated: 3/22/24 . Interventions: . Provide positive redirection when I am going into other residents rooms or laying in other residents beds. Offer phrases such as here, take my hand, this is your wheelchair, I can show you where you room is, then redirect me towards my room. Date Initiated: 3/6/24 . Wander Guard Bracelet Date Initiated: 3/22/24 . Focus: I don't have the ability to consent to a sexual relationship. I am a vulnerable adult. I will seek relationships with males for a connection. Date Initiated: 2/28/23. Goal: Resident will remain safe and other will remain safe. Date Initiated: 3/17/23. Interventions: Ensure I am safe from abuse . Monitor my whereabouts in relation to any individuals that my harm me or upset me. Monitor my whereabouts in relation to males that I am interested in. Ensure others are safe from unwanted attention. Date Initiated: 6/14/23 . Focus: I have a potential psychosocial well-being problem, sexually inappropriate behavior, r/t Alzheimer's Disease, Delusions. Date Initiated: 6/13/23 . Interventions: . When I start to seek out male residents/visitors please redirect me to a different room and provide distraction with my photo album, balloon activity, folding laundry . Date Initiated: 6/13/23 . Focus: I have impaired cognitive function r/t Alzheimer's. I may wander about the unit looking for things and may put myself in danger of exiting . Date Initiated: 2/28/24 . Goal: I will be able to communicate basic needs on a daily basis through the review date. I will stay safe while I'm moving about and not to leave the facility. Date Initiated: 2/28/23 . Interventions: . Cue, reorient and supervise as needed. Date Initiated: 2/28/23 . It is important to note that R51 does not have a stop sign in her care plan. On 6/24/24 at 10:17AM, Surveyor observed a stop sign on R51's door with the door closed. The facility documented the following progress notes for R51. *1/30/24 at 2:00 PM: Resident has been noted to be going into other resident rooms and laying down on their beds then will get agitated when staff try to redirect her to her own room. Resident was noted to be in another residents room and sitting on the resident bed while they were sleeping in their bed. CNA (Certified Nursing Assistant) and LPN (Licensed Practical Nurse) had to assist resident off the other resident who remained sleeping throughout the encounter. On 3/8/24 at 7:35 AM, Administration progress note states, in part, resident is opening the doors to other resident rooms and entering. when resident is told this is not your room, resident continues to enter the room, when staff attempt to remove resident, resident puts her feet down to make it more difficult to move her . On 3/11/24 at 3:25 PM, Behavior progress note states, in part, Resident was noted to be going into other residents rooms and going back and forth in her wheelchair down the hallways. Resident was frequently asking on how to get out to the parking lot and how to get out of here. Resident also stated she was hungry and was given food and a drink by nursing staff. Resident became slightly agitated when she kept getting re-directed towards her room. Resident was assisted by this writer into her room so she can lay down as that what is what she told staff. Resident stated, you're an ass. Resident was resting in her bed at the end of this interaction . On 3/26/24 at 2:31 PM, Behavior progress note states, in part, Resident was noted to be grabbing onto staffs clothes as they walked by her in the hallways. Resident was noted to be agitated towards other residents that were in her way in the hallways and pulled on other's chairs. Resident was provided 1:1 interaction and given a sandwich. Resident was re-directed to her room and assisted with laying down but then got back up 2 minutes later. Resident has not had any visitors today or known triggers . *4/8/24 at 1:41 PM: Resident entered another resident room this morning and took the blanket he was using from him. Resident has been going into other resident rooms, taking down, or going under the stop signs. When resident is shown where her room is resident grabs the doorframe so she can't go in. On 4/9/24 at 7:02 AM, Social Services progress note states, in part, This writer attempted to speak to resident in regard to entering into other residents rooms uninvited. This writer could not get a response from the resident. We will continue to use the stop signs. Moving forward we will attempt to figure other ways that could redirect the resident. This writer will continue to monitor behavior . *5/10/24 at 12:35 PM: Resident is observed coming in and out of different rooms. Resident is observed trying to eat other residents' food in the dayroom; staff tries to redirect the resident with 1:1 conversation. Resident is noted to be trying to push other individuals in their chairs and stating, give me back the thing you took from me. Resident is redirected by staff, but the resident continues to go in and out of rooms frequently. *5/13/24 at 12:37 PM: Resident was found in another residents room trying to lay down on their bed. Staff attempted to redirect the resident by offering to take the resident to her own room. Resident stated, I want to lay here This is my room. Additional staff tried to redirect the resident back to her own room to show her where she can lay down. Resident stated, I'm going to kill you and was observed trying to hit nursing staff. Resident was able to be redirected to her own room and was assisted to lay down in her bed as she requested. Staff will continue to monitor resident at a safe distance and try reproaching her later if needed. It should be noted that these progress notes do not indicate what resident rooms R51 was going into. Example 3: R1 was admitted to the facility on [DATE]. Her most recent MDS (minimum data set), dated 4/21/24 includes a BIMS score (Brief Interview for Mental Status) of 14, indicating R1 is cognitively intact. On 6/24/24 at 11:28 AM Surveyor asked R1 why she had a stop sign draped across her door. R1 stated that R51 had come into her room on one occasion and laid in her bed. On another occasion, R51 had come into her room and used her bathroom, leaving a mess in the bathroom. R1 stated this happened about 5 weeks ago. R1 stated the stop sign in her doorway was to keep R51 out. R1 believed the stop sign to be effective, but stated she was afraid of R51 because when she comes in, she won't leave. Example 4: R48 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease. Her most recent BIMS score, dated 1/16/24, was 0, indicating R48 is severely cognitively impaired. On 6/26/24 at 9:18 AM, CNA F (Certified Nursing Assistant) stated that she had witnessed R51 go into R48's room. R48 did not have a stop sign on her door way and should. CNA F indicated R48 was not offered a stop sign, the stop signs on various doorways are there because those residents vocalized that they did not want R51 in their room and would like the stop sign. Example 5: R45 was admitted to the facility on [DATE] and has the following diagnoses of generalized anxiety disorder and unspecified dementia. R45's most recent MDS dated [DATE], states a BIMS score of 7 out of 15, indicating R45 is severely cognitively impaired. R45 can understand and is understood. On 6/24/24 at 10:22 AM, Surveyor observed a stop sign across R45's door while he was sitting in his room. Surveyor interviewed R45 during initial screening. Surveyor asked R45 of the reasoning for the stop sign across the door. R45 indicated it was because of the resident next door that likes to come into his room and lay on his bed. R45 reports he can get her out and that she goes into a lot of rooms. R45 reports that sometimes R51 will take the stop sign down when R45 is sitting right in his room. R45 stated I feel like, what the hell are you doing in here. R45 reports that he may have scared her one day when he told R51 she couldn't come in and then she tried to push the door and R45 kept telling her no. R45 reports that they got a little loud and he pushed the door shut on R51 and then she yelled at him. R45 reports that R51 was yelling you hit me, and you hurt my hand. R45 reports he has never touched R51 or hit her. R45 indicated this happens 2 dozen times a day or a couple of times a day when R51 comes into his room. On 6/26/24 at 2:16 PM, Surveyor interviewed CNA X. Surveyor asked CNA X about R51's behavior, she indicated that it was extremely difficult to handle R51, R51 is quick tempered and a very short capacity for listening. Surveyor asked CNA X if R51 goes into other residents' rooms, she indicated yes, all the time and indicated R45 and several other residents. Surveyor asked CNA X the process of what she will do when R51 goes into other rooms, she indicated that they inform the nurse, and they document. Surveyor asked CNA X how R51 is being monitored, she indicated the only time the staff intervene is when there is a confrontation with another resident. CNA X further indicated there have been times that R51 takes other resident's food in the dining room, and we redirect her a lot. CNA X indicated that if they cannot find her, they know she is in a resident's room. Surveyor asked CNA X if R51 stops at the stop signs, she indicated that R51 takes the stop signs down and goes through them, it really does not help the situation. It is important to note that R51 is entering R45's room uninvited. Example 6: R35 was admitted to the facility on [DATE] and has the following diagnoses of cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it that can cause parts of the brain to die off due to lack of oxygen) and major depressive disorder. R35's most recent MDS dated [DATE], states a BIMS score of 4 out of 15, indicating R35 is severely cognitively impaired. R35 sometimes understands and sometimes is understood. On 6/24/24 at 10:59 AM, Surveyor observed a stop sign across R35's door while he was sitting in his wheelchair in his room. Surveyor interviewed R35 during initial screening. Surveyor asked R35 of the reasoning for the stop sign across the door. R35 indicated that a lady comes in and then crawls into my bed, identifying R51. R35 stated that he points to the door to chase her out and tells her to get out. Surveyor asked R35 if R51 has touched him, he indicated yes, his shoulder and pushing me. R35 further indicated that the staff come and get R51 out. It is important to note that R51 is entering R35's room uninvited. Example 7: R66 was admitted to the facility on [DATE] and has the following diagnoses of epilepsy, congestive heart failure and renal insufficiency. R66's most recent MDS dated [DATE], states a BIMS score of 13 out of 15 indicating R66 is cognitively intact. R66 can understand and is understood. On 6/26/24 at 2:10 PM, Surveyor observed R66's stop signs down with a visitor in the room. Surveyor asked R66 the reasoning for the stop sign on the door. R66 indicated that she sleeps very sound, even a thunderstorm does not wake her up. R66 reported that one night, R51 came into her room and touched her foot and woke her up.

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from physical abuse by a resident (R1). This affected 3 of 6 residents (R4, R5, and R6) reviewed for abuse. R1 has a history of resident-to-resident incidents including punching a resident in the back (R4), punching a resident in the face, putting a resident in a choke hold and banging her head on the wall, hitting the resident in the head and chest and pushing her into a chair and grabbing her wrist. The facility failed to update R1's care plan with new interventions after the incidents to prevent further abuse. The facility failed to ensure that R1's line of sight monitoring was completed to prevent further incidents. The facility was aware of R1's behaviors of hitting, punching, grabbing, yelling, and swearing at other residents and staff. The facility's failure to care plan interventions and ensure that increased supervision was completed resulted in R1 abusing R5 and R6 creating a finding of Immediate Jeopardy (IJ) that began on 2/3/24. Staff report that R6 comes out of her room less frequently now. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the Immediate Jeopardy on 3/1/24 at 2:00 PM. The immediate jeopardy was removed on 3/1/24; however, the deficient practice continues at a scope/severity of D (no actual harm with potential for more than minimal harm, isolated) as the facility continues to implement its action plan. Evidenced by: The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, includes, in part, the following: Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. 6. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. 10. Protect residents from any further harm during investigations. Interventions can include increased supervision. The lowest level supervision should be used to meet immediate safety needs. b. 1:1 line of sight This means that the resident is in sight and the staff is able to intervene if necessary. R1 was admitted [DATE]. R1's diagnoses include late onset dementia/mixed dementia and traumatic brain injury (TBI). R1's Minimum Data Set (MDS), dated [DATE], indicates R1 has severe cognitive impairment, has delusions, and no identified behaviors. R1 ambulates with supervision. R1's Care Plan includes, in part, the following: Focus: I am dependent on staff for meeting emotional, intellectual, physical, and social needs, initiated 2/7/24. Interventions: All staff to converse with me. Encourage ongoing family involvement. Invite my family to attend special events, activities, meals. Establish and record my prior to level of activity involvement and interests by talking with me, caregivers, and family on admission and as necessary. I need assistance/escort to activity functions. Invite me to scheduled activities. My preferred activities are: small group activities, visiting with my family, talking about being an iron worker, walking outside when the weather is good, musical activities, etc. Provide me with materials for individual activities as desired. I like the following independent activities: 1 on 1 visits with staff and residents, looking through fishing, hunting and animal books/magazines, watching hunting, fishing and animals on the television/iPad, listening to music (country western, piano, soft music), enjoys the cast on the unit, etc. Provide with activities calendar. Notify me of any changes to the calendar of activities. Review my activity needs with the family/representative. Thank me for attendance at activity function, all care plan interventions initiated 2/7/24. Focus: The resident is/has potential to be physically aggressive towards staff r/t (related to) dementia, TBI (traumatic brain injury), History of harm to others, initiated 1/18.24, revised 2/12/24. Inventions: Analyze times of day, place, circumstances, triggers, and what de-escalates behavior and document. This may include sleep amount, previous negative contacts, pain in legs, initiated 1/18/24, revised 2/12/24. Assess and address for contributing sensory deficits, initiated 1/18/24. Give me as many choices as possible about care and activities, initiated 1/18/24. I will remain in the DSU (dementia stabilization unit) area for smaller area monitoring until I am able to transfer to a facility that is more appropriate for me with my brain injury. When I come out of the DSU to the larger part of the facility I can come out with 1:1 with staff member or family. I will be brought out of my room on the unit each night where I will sleep. If I get up during the night to wander, I will be returned to the DSU at that time. I will have my room door alarmed to notify staff of my awakening, initiated 2/26/24, revised 2/27/24. Monitor each shift. Document observed behavior and attempted interventions in behavior log, initiated 1/18/24. Monitor/document/report PRN (as needed) and s/sx (signs or symptoms) of me posing danger to self and others, initiated 1/18/24. Psychiatric/Psychogeriatric consult as indicated, initiated 1/18/24. Review behavior summary including triggers and approaches to be utilized. These may include but are not limited to: residents approaching him fast or in a manner that he feels he needs to protect self or persons who move fast or are loud, initiated 2/5/24, revised 2/23/24. When I become agitated: Intervene before agitation escalates; Guide me away from source of distress; Engage me calmly in conversation; If my response is aggressive, staff to walk calmly away, and approach me later, initiated 1/18/24. I can have a delusion that someone has hit me and that I should to [sic] retaliate physically. This may occur the first moments when I wake up before I am fully awake, initiated 1/19/24. Interventions: Assist me to develop more appropriate methods of coping and interacting seeking out staff. Encourage me to express feelings appropriately, initiated 2/23/24. Educate me/family/caregivers on successful coping and interaction strategies such as removed from environment and return to room. I need encouragement and active support by family/caregivers when I use these strategies, initiated 1/19/24, revised 2/21/24. If reasonable, discuss my behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to me, initiated 2/23/24. Intervene as necessary to protect the rights and safety of others. Approach/Speak to me in a calm manner. Divert attention. Remove from situation and take to alternate location as needed, initiated 2/23/24. Minimize potential for my disruptive behaviors striking out by offering tasks which divert attention such as visiting with staff, initiated 2/23/24. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes, initiated 2/23/24. My triggers for striking out is belief someone is trying to harm me. My behavior is de-escalated by talking about where he is, initiated 2/23/24. Praise any indication of my progress/improvement in behavior, initiated 2/23/24. Provide a program of activities that is of interest and accommodates my status, initiated 2/23/24. Focus: I have impaired cognitive function/dementia or impaired thought process r/t (related to) brain surgery, initiated 1/18/24, revised 2/5/24. Communication: Use my preferred name Identify yourself at each interaction. Face me when speaking and make eye contact. Reduce any distractions - turn off TV (television), radio, close door, etc. I understand consistent, simple, directive sentences. Provide me with necessary cues - stop and return if agitated, initiated 1/18/24. Cue, reorient, and supervise as needed, initiated 1/18/24. Engage me in simple, structured activities that avoid overly demanding tasks, initiated 1/18/24. I need assistance with all decision making, initiated 1/18/24. Present just one thought, idea, question, or command at a time, initiated 1/18/24. Focus: I use Seroquel and Citalopram, r/t poor adjustment to communication deficits, psychosis (delusions/hallucinations, initiated 1/18/24, revised 2/5/24. Interventions: Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT (every shift) initiated 1/18/24. Monitor/document/report PRN (as needed) adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal, decline in ADL (activities of daily living) ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs (problems), movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt. (weight) loss, n/v (nausea/vomiting), dry mouth, dry eyes, initiated 1/18/24. R1's Certified Nursing Assistant (CNA) Kardex states in part . Behavior/Mood: If reasonable, discuss my behavior. Explain reinforce why behavior is inappropriate and/or unacceptable to me. Intervene as necessary to protect the rights and safety of others. Approach/speak to me in a calm manner. Divert attention. Remove from situation and take to alternate locations as needed. Monitor each shift. Document observed behavior and attempted interventions in behavior log. My triggers for striking out is belief someone is trying to harm me. My behavior is de-escalated by talking about where he is. Praise any indication of my progress/improvement in behavior. When I become agitated: Intervene before agitation escalates; Guide me away from source of distress; Engage me calmly in conversation; If my response is aggressive, staff to walk calmly away, and approach me later. R1's behavior monitoring states in part . 1/19/24 - Entering other resident's rooms/personal space, repetitive motions, anxious/restless, wandering. 1/20/24 - Grabbing others, pushing others, disrobing in public, entering other resident's rooms/personal space, rummaging, agitated, elopement/exit seeking, repetitive movements. 1/24/24 - disrobing in public, entering other resident's rooms/personal space, repetitive motions, rummaging, agitated, anxious, restless, elopement/exit seeking, insomnia/not sleeping, refusing care, wandering. 1/25/24 - Grabbing others, pushing others, physically aggressive towards others, express frustration/anger at others, entering other resident's room/personal space, agitated, pacing. 1/26/24 - entering others resident's rooms/personal space, rummaging, anxious, restless, elopement/exit seeking. 1/27/24 - entering others resident's rooms/personal space, refusing care. 1/28/24 - physically aggressive towards others, pacing, refusing care, disrobing in public, entering other residents' rooms/personal space, insomnia/not sleeping. 1/29/24 - physically aggressive towards others, anxious/restless, pacing, hitting others, physically aggressive towards others, agitated. 2/1/24 - pushing others, physically aggressive towards others, cursing at others, express frustration/anger at others, threatening others, agitated, anxious/restless, pacing and wandering. 2/7/24 - physically aggressive towards others, pacing and wandering. 2/8/24 - Express frustration/anger at others, agitated, anxious, restless, hallucinations. 2/9/24 - agitation, elopement/exit seeking, pacing, and wandering. 2/12/24 - wandering, withdrawn/isolating. 2/15/25 - anxious, restless, and pacing. 2/21/24 - hitting others and agitation. R1's Nurse's Note from 1/23/24 at 12:18 PM states, Behavior Note: Resident had a phone call with an attorney regarding a court proceeding that was occurring tomorrow. Resident was able to answer the attorney's questions but then became frustrated when he was trying to ask a question but couldn't find the words to say. Resident ended the conversation promptly and walked into the hallway. Resident was noted to be pacing up and down the hallway still frustrated. DON (Director of Nursing) walked with the resident and provided 1:1 conversation. This writer offered the resident a snack or something to eat and he responded, yeah I'll give you this kind of snack and put his fist up. Nursing staff tried calling the residents wife, and while it was ringing the residents was noted to be crying and put his head down on the nurses station. Resident them spoke with his wife, but then continued to be frustrated while he was listening then hung up the phone during the conversation. DON continued to provide 1:1 interaction with the resident as he started to pace the hall again but then he did sit down and eat lunch. Resident seemed to less frustrated after he was done eating lunch. R1's Nurses Note from 1/23/24 at 21:49 (9:49 PM) states, wandering in and out of rooms. Staff report did strike out at CNA. R1's Nurses Note from 1/23/24 at 21:49 (9:49 PM) states, Behavioral Note: After supper resident wandering and going in and out of other residents rooms. He was walking faster and faster, putting his body in front of other staff. Staff reports he did try to strike at CNA. He did not with this writer, I kept distance away from him, called supervisor. CNA familiar with resident did one on one with resident. Administrator came in and spent time with him. Now resident resting quietly. R1's Nurses Note from 1/24/24 at 22:37 (10:37 PM) states, wandering going in other resident rooms. Stop signs put up but he still going into resident rooms. Some other residents yelling at him to get out of room. Staff assisting him out. Ice cream offered. R1's Nurses Note from 1/25/24 at 11:59 AM states, R1 moved to Lane unit on admission. Room coming available on View unit and scheduled to move 1/29/24. Example 1 (This example does not rise to the level of immediate jeopardy): R4 was admitted to the facility on [DATE] with diagnoses of dementia, anxiety and depression, and severe cognitive impairment. R4's care plan states in part . Focus: I have the potential to be physically aggressive r/t dementia, initiated 4/24/23, revised 8/15/23. Interventions: Monitor each shift. Document observed behavior and attempted interventions in behavior log, initiated 8/15/23. Monitor/document/report PRN any s/sx of me posing danger to self or others, initiated 8/15/23. When I become agitated: Intervene before agitation escalates; Guide me away from source of distress; Engage me calmly in conversation; If my response is aggressive staff to walk calmly away, and approach me later, initiated 8/15/23. Focus: I may have a history of behaviors of striking out at bedtime r/t dementia, initiated 4/24/23, revised 4/25/23. Interventions: I like my stuffed animal with me, initiated 8/08/23. R4's CNA Kardex states in part . Resident Care: Ensure I am safe from abuse due to being a vulnerable adult. If concerned abuse may have occurred I require a skin check to identify any signs of physical abuse. If I have a change in emotion evaluate for possible abuse. Monitor my whereabouts in relation to any individuals that may harm me or upset me. Behavior/Mood: When I become agitated: Intervene before agitation escalates; Guide me away from source of distress; Engage me calmly in conversation; If my response is aggressive staff to walk calmly away, and approach me later. The facility's Misconduct Incident Report includes in part the following: Date occurred, 1/29/24. Briefly Describe the incident: R1 came into the lounge on the Lane unit and walked by R4 striking her on the back. He then struck out at staff member hitting her on the back when she was trying to redirect him. He was running around the tables in the lounge and grabbed a can off of the housekeepers cart from behind the housekeeper throwing it across the room. He was then removed back to the View unit where his room is located and was watched by staff until he calmed down. Describe the Effect: No effect of R4. She was not injured and had no psychosocial affects. Repeated skin checks continued to show no injury. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct: Staff removed R1 back to the View unit and staff on the View unit supervised him until he calmed down. A write up was completed stating what his triggers are and signs of anxiousness that will escalate to striking out. A list of interventions and approaches were completed, and care planned to help staff identify problems before they escalate to his striking out. The facility document titled Follow-up Investigation Report for Resident-to-Resident R1 and R4, undated, states in part . 4. Corrective Action(s) Taken. Describe any action(s) taken as a result of the investigation or allegation. Staff were provided with a write up discussing the interventions needed to help calm R1 and how to approach him to reduce his aggression. He is redirected to the View unit when he enters the Lane unit, and it appears he has been receptive to this. He has had no other incidents on the lane unit. The information sheet also includes triggers for R1 and what to watch for and when to intervene. Note: Care plan was not updated following this incident to prevent further abuse. R1's Nurses Note from 1/29/24 at 10:54 AM states, assisted with move from Lane to View unit. R1's Nurses Note from 1/29/24 at 22:53 (10:53 PM), Wandering on view unit at times this shift redirects but at times will show flashes of irritation towards staff - turns away suddenly, frowns, did raise arm x1 (times 1) to nurse. R1's Nurses Note dated 1/29/24 at 14:10 (2:10 PM) states, Following R1's move to the View unit this morning he was witnessed going into the lane unit lounge and running around tables and striking another resident on the back and striking a staff member on the back. He was also witnessed throwing a spray can. There were no injuries, and he was calmed down. Guardian was notified. R1's Nurse's Note dated 1/30/24 at 12:04 PM states, Note Text: Follow up to resident-to-resident concern. Staff has been monitoring residents behavior since knowing of incident. Resident did come over on the lane unit today, 1/30/24. However, the view unit was able to redirect resident back to the view unit successfully. R1's Nurses Note from 2/1/24 at 8:02 AM, Resident was up all night shift this NOC. He was trying to hit staff, throw objects at staff, pacing back and forth down halls, exit seeking, swearing at staff, trying to bite and elbow staff. He was also trying to pull the shadow boxes off the walls and banging on the windows. On 2/29/24 at 3:30 PM, Surveyor interviewed CNA O (Certified Nursing Assistant). Surveyor asked CNA O about any incidents she witnessed with R1. CNA O stated, I was in the dining room with the residents. R1 came by R4 and turned around and hit R4 in the back. I then went to redirect R1, and he turned on me and punched me in the back. R1 ran around the table and went after the housekeeper. I was able to intervene before R1 could hit the housekeeper. R1 then took an aerosol can off the housekeeping cart and threw it across the room. R1 then tried to get the broom off of the cart and I was able to redirect him from the unit. R1 was taken back to the view unit where his room was. There were 3 other residents in the dining room at the time of this incident. R4 did nothing to provoke R1 and I didn't see it coming. I have seen him angry before but never have seen him go after a resident before or after that. R1 still wanders the units a lot. There has been no education on R1's behaviors or dementia care. Surveyor asked CNA O if she has seen the document about R1's diagnoses, interventions, likes and dislikes. CNA O stated, I have not seen that document. CNA O stated it would have been good for both units to see. On 2/29/24 at 11:15 AM, Surveyor interviewed HSK J. Surveyor asked HSK J if she ever saw any resident-to-resident interaction involving R1. HSK J stated R1 was on the Lane Unit and one morning HSK J came around the corner by the Lane Unit common area with her housekeeping cart; R1 was in a bad mood, a CNA was trying to get R1 away from the common area. R1 grabbed a can from HSK J's housekeeping cart and R1 threw the can at a door. The CNA told HSK J to keep going and R1 grabbed a mop handle, the CNA got the mop handle from R1 and HSK J moved on down the hall. Example 2: R5 was admitted to the facility on [DATE] with diagnoses that include acute respiratory failure with hypoxia, anxiety, trans ischemic attack (TIA), and congestive heart failure (CHF). R5 has a Brief Interview of Mental Status (BIMS) of 14 indicating she is cognitively intact. R5's care plan states in part . Focus: I have an ADL (activities of daily living) self-care performance deficit r/t (related to) impaired balance. Interventions: It is recommended that 2 staff care for me at all times, to help decrease risk of unjust accusations towards staff. Focus: I have a mood problem r/t I am ready to die, and it is not happening fast enough for me. This causes me anxiety at times. I will refuse care frequently which may cause me pain and discomfort which will increase my anxiety. Due to my anxiety, I have a history of getting upset with the staff and will at times yell at them due to things I perceive they have done to me. This at times will manifest as accusations against staff and at other times I will just yell at them. Interventions: Allow me to feel I have control of the conversation we are having, keep interactions brief if I am feeling tired or overwhelmed. Follow my lead for conversations. This helps me feel a sense of control and decreases my anxiety, initiated 4/27/23. Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.), initiated 4/22/23. Encourage her to take pain medication to keep pain under control and reduce anxiety feelings, initiated 10/17/23. I need support to maintain as much independence and control as possible. My strengths can ask for help, can express feelings, initiated 4/22/23, revised 4/22/23. I need time to talk upon request. Encourage me to express feelings, initiated 4/22/23, revised 4/22/23. Observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity, initiated 10/17/23. R5's CNA Kardex states in part . Monitors: Monitor/record/report to MD prn (as needed) risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM (range of motion), withdrawal or resistance of care. Resident care: 2 staff must be present for all personal care. Encourage me to participate to the fullest extent possible with each interaction. Allow me to feel I have control of the conversation we are having, keep interactions brief if I am feeling tired or overwhelmed. Follow my lead for conversations. This helps me feel a sense of control and decreases my anxiety. I show this by: exhibiting fluctuations in my ability to perform ADL (activities of daily living), memory loss, appetite, pain and health status. It is recommended that 2 staff care for me at all times, to help decrease risk of unjust accusations towards staff. Behavior/Mood: I need support to maintain as much independence and control as possible. My strengths are: can ask for help, can express feelings. The facility's Misconduct Incident Report includes, in part the following: Date occurred 2/3/24. Briefly Describe the incident: R1 was witnessed striking R5 with an open hand on the right side of her head. Describe the Effect that the incident had on the affected person, the person's reaction to the incident, and the reaction of others who witnessed the incident. R5 was startled and had some tenderness on her jaw area following the incident. She was angry with the incident but has seemed to resolve her feeling with it due to it being addressed. Explain what steps the entity took upon learning of the incident to protect the affected person(s) and others from further potential misconduct. Immediately following the event R1 was taken to the DSU for 1:1 with staff. He remained 1:1 with DSU staff through the weekend and continues to work with them on addressing behaviors. Staff Statement, dated 2/3/24 written by CNA D states in part . As I got off the elevator around 6:30 AM on the View unit, I saw R1 have a tight hold on the NOC RA (Resident Assistant) (name unknown) arm, wouldn't let go and yelling in her face. Once he let go, she went back to Lane (unit). R1 walked down the halls on the View unit punching the wall and mailbox. That's when the NOC (night) CNA walked near him and tried redirecting him back to his room, as this was happening, I was getting report on residents from the NOC CNA, soon after we heard R1 yelling at NOC CNA and her telling him to let go. He had a tight hold on her arms, tried tripping her, and then R1 stuck the NOC CNA with a closed fist in the face. As the NOC CNA finally got let go, he started chasing towards us and the residents while his pants and brief were down by his ankles. Then a CNA from Lane unit came over to help and got him in his room for a few minutes. As I was getting residents up for breakfast, R1 was pacing the View unit, going into other residents' rooms playing with their belongings. As I was exiting a room, I heard a resident yell, when I ran over, the nurse was leading R1 out of R5's room, yelling and trying to fight against the nurse, then I was told to call the DON (Director of Nursing) and notify her. That's when she came up and R1 was lead [sic] back into the DSU. The facility document titled Follow-up Investigation Report for Resident-to-Resident R1 and R5, undated, states in part .Corrective Action(s) Taken. Immediately following the event R1 was taken to DSU for 1:1 treatment with staff. R1 is fully in agreement with working on the goals of 1) resisting the temptation to go into people's rooms and 2) learning the keys to calm down after getting angry. R1 remains living in the nursing home but received 1:1 treatment as well. Staff will receive further training as more successful interventions are discovered. R5 was offered support and an opportunity to move off of the dementia unit to a unit with less activity and fewer residents that wander. R5 again has refused to move at this time and wants to be left alone. R5 is angry and has refused traditional means of counseling or treatment, but it appears that by making a report and talking to family she is coming to peace with the event. R5 has a supportive family that talks with her frequently, and their talks help her with her anger and feelings of injustice over this event. R5 has felt validation by giving a report to the [County Name] Sheriff's Department. While she has no expectations of punishment, it was helpful for her to see that it was treated as an unacceptable event. R1's Nurses Note from 2/3/24 at 9:05 AM: Resident will stay in the DSU for a 2:1 with staff through the weekend. R1's Nurses Note from 2/3/24 at 10:04 AM: Resident punched another resident. Resident immediately removed from the unit and placed on DSU. Resident will stay in DSU for a 2:1 with staff through the weekend. On 2/28/24 at 3:30 PM, Surveyor interviewed R5. Surveyor asked R5 about an incident that happened a few weeks prior. R5 stated, I was in my room, R1 took down the Velcro stop sign across the doorway. R1 came in walked over to me and punched me on the right side of the face with a closed fist. There were no staff around when this happened. I did not yell or scream, I just said, Hey, and he came over and punched me one time. R1 just stood there and then 2 staff showed up and walked R1 away. I sat there stunned I couldn't get up and go after him, I was scared. I am scared of him and have had nightmares since this happened. No staff came in and talked with me or asked if anything happened until later. My niece and nephew came in later and I told them what happened. My niece left and went to the police station. When I asked why R1 was still walking around unsupervised I was told, He lives here. I would like to move back to my room on the second floor if R1 won't be able to come in again; I don't like this room. On 2/28/24 at 4:28 PM, Surveyor interviewed FM K (Family Member). Surveyor asked FM K about incident that happened with R5 that was reported to him by the facility. FM K stated, I was notified by the DON that R5 was hit, and they were still trying to get information. It was a very basic notification. I was assured that R5 had no injury but was offered pain medication and ER (emergency room ) evaluation. I was also told that R1 was on a locked unit. I felt that this was just reassuring me. I contacted SW H to inquire about what the plan was, and SW H indicated that he had not seen anything about the incident yet and would get back to me. I went to the facility to visit R5 on Monday and SW H came in and indicated that R1 had other incidents needing to be looked at. SW H brought up R5 moving to another unit which R5 did not want to discuss at the time. R5 then later brought up moving, so staff moved her to the 1st floor. Since the move R5 has brought up wanting to move back to her old room. I let SW H know that we were concerned that R1 was still able to roam around freely. On 2/29/24 at 8:35 AM, Surveyor interviewed FM L. Surveyor asked FM L about the incident with R5. FM L stated, I was out of town. I was in meetings and my phone was ringing. I didn't answer the call, so they called FM K. When I came back to town, I talked with R5 and asked if she wanted to press charges and R5 stated, yes. I then called the police from home, no one called back so I went to the Sheriff's Department who then came to the facility and took pictures and R5's statement. On 2/29/24 at 9:20 AM, Surveyor interviewed SW H (Social Worker). Surveyor asked SW H about the incident between R1 and R5. SW H stated, I want to say that happened over the weekend and I was told on Monday. I then talked with R5. The IDT (Interdisciplinary Team) came up with a plan to move R5 to 1st floor to prevent this from happening again. Initially R5 refused to be moved but was later receptive. Surveyor asked SW H if he follows up with R5. SW H stated, I follow up with her on occasion. Surveyor asked SW H if he was aware that R5 was interested in moving back to her old room. SW H stated, I have heard she wants to move again but I have not asked her about wanting to move, she will tell you. I was not really involved with the aggressor but with R5 and the move. On 2/29/24 at 10:10 AM, Surveyor interviewed SSS C (Social Services Supervisor). Surveyor asked SSS C about the incident between R1 and R5. SSS C stated, R1 was seen by the RN going into the room but the RN never saw the incident with R5. R5 had been asked about moving in the past, would agree, then would cancel the move the day she was scheduled to move. Following the incident with R1, I took a video of the new room that we were considering moving R5 into, b [TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 5 residents reviewed (R35) of a total sample of 21. R35 has a history of multiple falls. Facility staff did not implement fall interventions. R35 had a fall that resulted in a right pubic rami fracture (pelvic fracture). This is evidenced by: R35 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, Chronic Kidney Disease stage 4, Major Depressive Disorder, Anxiety Disorder, Spinal Stenosis, and Osteoporosis. R35's most recent MDS (Minimum Data Set) dated 12/13/22 states that R35 has a BIMS (Brief Interview of Mental Status) of 4/15 indicating that R35 is severely cognitively impaired. Section G states that R35 requires extensive assist of 2 staff for bed mobility and transfers. R35's care plan dated 5/26/22 states in part, I: am at risk to fall down and hurt myself .I like a low bed with cushion, keep personal items within reach .when I'm up in my chair, keep me where you can see me. R35's care plan dated 1/31/23 states in part, I am high risk for falls r/t (related to) confusion, gait/balance problems, poor communication/comprehension, psychoactive drug use, unaware of safety needs .Interventions .Ensure that I am wearing appropriate footwear non-skid shoes or non-slip socks when ambulating or mobilizing in w/c. R35's fall risk assessments are documented as follows: 5/2/22: score 21 - at risk 12/10/22: score 13 - at risk The facility did not complete a fall risk assessment with each fall, nor did they complete them quarterly. R35's fall reports list the following falls: 4/8/22 - unwitnessed fall in the bathroom - Resident was ambulating independently in her bathroom. This fall resulted in hematoma to left occipital (back of head,) resident was sent to the emergency room . The facility fall report documents Measures to prevent falls as: She has a walker and was dressed with appropriate footwear, resident is independent in bathroom. Plan for safety was documented as: We are getting her a pendant to wear so that she can call for assistance with ease, will do PT (Physical Therapy) Eval and Treat order to see if resident is still appropriate to be independent in bathroom, we will give cues/reminders to resident to always use walker when ambulating even in bathroom for stability. 4/21/22 - unwitnessed fall in room, no apparent injury - resident dropped remote and bent down to pick it up and slid out of recliner. The facility fall report documents Measures to prevent falls as: She has pendant call light, PT has evaluated her, we give cues/reminders. Plan for safety was documented as: Will put a clip on recliner remote to hold it in place. 4/24/22 - unwitnessed fall in room - slid out of recliner d/t (due to) restless legs. The facility fall report documents Measures to prevent falls as: Call light in reach, call pendant on res.(resident), walker locked in front of res. Plan for safety was documented as: Dycem grip to recliner chair, w/c (wheelchair) seats, gripper socks. 4/28/22 - unwitnessed fall in room - found on floor by staff. The facility fall report documents Measures to prevent falls as: Keep recliner remote clipped to arm of recliner. Plan for safety was documented as: Assisted resident to bed. Offer recliner by nurses [sic] station, dycem in recliner in her room. 4/29/22 - unwitnessed fall in room - resident was sitting in recliner, staff found on floor by dresser and television. The facility fall report documents Measures to prevent falls as: Now repositioned in recliner at nursing station so staff can closely monitor her. Plan for safety was documented as: Will call Hospice about her terminal restlessness. 4/29/22 - unwitnessed fall in room - was in recliner, restless and slid out of recliner. The facility fall report documents Measures to prevent falls as: Dycem was present in the recliner- a bigger piece would be appropriate. Plan for safety was documented as: Relaxation music, fidget toy, medications started for UTI (Urinary Tract Infection) and Restless Legs, and lap buddy request to MD (Medical Doctor) for w/c to help with sliding when restless, out in common area while awake. 5/26/22 - unwitnessed fall in room - attempted to self-transfer out of geri-chair. The facility fall report documents Measures to prevent falls as: Low bed with cushion, geri chair, personal items in reach. Plan for safety was documented as: When up in geri chair, keep resident where she can readily be observed by staff. 5/27/22 - unwitnessed fall - resident had a fall from bed, attempting to go to the bathroom. The facility fall report documents Measures to prevent falls as: Matt to floor, frequent checks, keep within sight when up. Plan for safety was documented as: Up earlier and toilet/toilet on night shift? 7/12/22 - unwitnessed fall due to transferring self from Broda chair. Resident was found sitting on her right hip/buttock on the floor in her room between the Broda chair and the open bed. This fall resulted in a right pubic rami fracture (pelvic fracture). The facility fall report documents Measures to prevent falls as: Broda chair with legs elevated, dysum [sic] on the chair seat, gripper socks, bed at low hight [sic], call light at residents [sic] side. Plan for safety was documented as: Talk to NCC (Nurse Care Coordinator) about a self release [sic] belt. It is important to note that the fall report for 7/12/22 indicates that R35 was alone in her room in her Broda chair. On 3/15/23 at 11:20 AM, Surveyor observed R35 in the unit's dining area sitting in her wheelchair, not wearing shoes or gripper socks; R35 was wearing regular socks. On 3/21/23 at 9:43 AM, Surveyor interviewed CNA J (Certified Nursing Assistant). Surveyor asked CNA J if she was able to recall R35's falls? CNA J stated that she did remember them and that R35 mostly fell out of her wheelchair and her bed. Surveyor asked CNA J if she recalled any of the interventions that were put into place? CNA J stated that they could not leave her alone in her room and staff had to be able to see her, she was kept within eyesight. On 3/21/23 at 10:10 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what her expectations were regarding R35 and her falls? DON B stated that she expected staff to keep R35 safe. DON B reported that R35 was on hospice, and they were trying to keep her comfortable and safe. Surveyor asked DON B if prior to her fall on 7/12/22, should R35 have been left in her room alone? DON B stated at that time, I would say yes; she liked to listen to polka music. Surveyor asked DON B if R35's care plan stated, in line of sight, should she have been alone in her room? DON B stated that intervention was not in place at the time of the fall. Surveyor reviewed R35's care plan with DON B. Surveyor asked DON B after reviewing the care plan, should R35 have been in line of sight? DON B stated yes. It is important to note that Surveyor requested a Fall Prevention policy and one was not provided.

Based on observation, interview, and record review the facility failed to ensure a resident has the right to be free from sexual abuse for 1 out of 3 sampled Residents (R2). R1 and R2 are both unable to consent to sexual activity based on their cognitive status and lack of sexual consent assessment. R2 was found on 9/14/22 alone with R1 in her room. R1 had his pants down and was holding R2's hand over his genitals. The facility's failure to ensure residents were free from sexual abuse created a finding of immediate jeopardy that began on 9/14/22. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 10/12/22 at 3:00 PM. The immediate jeopardy was removed on 10/15/22, however the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan. This is evidenced by: The facility policy titled, Abuse Prevention-Protection-Reporting Policy, with a revised date of February 2012, indicates, in part. Policy: Each resident has the right to be free from misconduct related to abuse, neglect, misappropriation of resident property, and injuries of unknown source. The facility will screen train, prevent, identify, investigate, protect and report as described in the procedure. The facility will provide a safe and secure environment and uphold resident's rights. Procedure: Misconduct Definitions: Neglect: Failure to provide goods and services necessary two avoid physical harm, mental anguish, or mental illness. Abuse: the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish . Prevention: * Caregivers as well as support staff will participate in education that will equip them to recognize signs of potential misconduct so that a prevention plan can be implemented. *At the regulator Behavior Management meeting, the interdisciplinary team will identify resident behaviors, such as altercations and develop a care plan to manage these behaviors appropriately . * All staff is encouraged to communicate concerns in order to plan for appropriate prevention of any type of misconduct. Investigation: * The Administrator and/or designee will direct and coordinate the investigation of the allegation to ensure that the investigation is thorough and completed timely manner. *The investigation will include but is not limited to the following and will be documented in the form of written statements, interview statements, observations, and correspondence. (Use Investigation Statement Form or the Skin Injury Statement Form) A summary of the investigation will be written in chronological order with references made to the corresponding attachment . *The investigation will collect the facts and pertinent observations surrounding the incident that was reported to allow for a thorough process as follows: -List the Reporting Information . -Document Information Regarding Alleged Incident . -Description of Immediate Action Taken (if any) (e.g., employee suspension or reassignment, care plan modification). -Summary of Investigation --Name(s)/Title(s) of Investigators --Date/Time Investigation Initiated --Name(s)/Title(s) of Witness(es) --Summary of Evidence Reviewed (if any) (e.g., nursing notes, physical evidence, timecards, staff schedule, e-mails) --Summary of Interviews (i.e., date/time, name/title interviewee, name/title of interviewer, summary of interview) -Summary of Investigation Findings (i.e., did alleged incident occur). -Information Regarding Reporting of Investigation to Outside Parties (e.g., police). -Description of Corrective/Preventive Measure (e.g., employee discharge, employee/staff training, policy revision, care plan modifications). Protection: *The victim of the alleged misconduct will be protected immediately in an appropriate manner. He/she will be removed from the situation to a safe location; the alleged party will be removed from the area; the work assignment may be changed or possibly the staff member may be suspended pending investigation. *The Supervisor and/or Social Worker will meet the resident to provide assurance that their safety, their rights, and their security will be upheld by the facility. The resident and appropriate HCPOA (Health Care Power of Attorney) will be notified that an investigation is being conducted with appropriate actions and follow through as necessary . Report: .*The Administrator and/or designee will report all alleged violations that meet the definition of abuse, neglect, misappropriation of resident property, and injuries of unknown source to the Division of Quality Assurance via the online reporting system .This report will be completed as soon as possible and will not exceed 24 hours after discovery of the incident . *Reporting Reasonable Suspicion of a Crime in a Long-Term Care Facility (LTC): Section 1150B of the Social Security Act (CMS Memo Ref: S&C: 11-30-NH) - Section 6703(b)(3) of the Affordable Care Act entitled reporting to Law Enforcement of Crimes Occurring in Federally Funded Long-Term Care Facilities. According to the article written by a member of the [NAME] University Law School, Grandparent Molesting: Sexual Abuse of Elderly Nursing Home Residents and its Prevention, Emotional signs and symptoms [of sexual assault in a nursing home] include denial, humiliation, flashbacks, intense fear, guilt, anxiety, depression, feelings of hopelessness and helplessness, phobias, and rage. These conditions are symptomatic of post-traumatic stress disorder or rape trauma syndrome. Because victims of sexual abuse are likely to be cognitively impaired, practitioners must consider additional effects of abuse. Often cognitively impaired individuals are unable to describe the assault event, the fears, or the feelings of helplessness. This makes it more difficult to provide these victims with necessary services because they are unable to express their needs. In addition, victims suffering from dementia, including Alzheimer's disease, often display post-rape emotional distress, including disorganized or agitated behaviors, sleep disturbance, and extreme avoidance of certain staff members. Research shows that sexual abuse may increase the victim's mortality. Injuries, but more significantly stress, from the assault may exacerbate other health conditions of the victim, such as hypertension and diabetes. http://scholarship.law.[NAME].edu/cgi/viewcontent.cgi?article=1066&context=elders In Sexual Abuse of Older Nursing Home Residents: A Literature Review, the authors note the statement by the World Health Organization, Regardless of the type of abuse [psychological, physical, sexual, financial, and neglect], it will certainly result in unnecessary suffering, injury or pain, the loss or violation of human rights, and a decreased quality of life for the older person https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 65/ R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Annual Minimum Data Set (MDS) assessment, with a target date of 8/30/22, indicates a Brief Interview of Mental Status (BIMS) score of 5, indicating, severe cognitive impairment. R1's Functional Assessment: is extensive assistance with one-person physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene. R1's mobility devices are a walker and a wheelchair. R1 has had one fall since admission without an injury. R1's Comprehensive Care Plan indicates, in part, I have the potential to feel anxious and paranoid I may: attempt to grab at staff inappropriately and/or more inappropriate sexual comments towards staff. Follow female resident on the unit. I need my nurses to- identify my patterns of behavior evaluate for my environmental triggers (e.g., Room temperature, positioning, noise level) Put Velcro stop sign on female residents' doorway to encourage me to stay out of room . I may make sexual comments to staff or believe that a female staff member is my girlfriend . (Note: Surveyor reviewed R1's record back until 3/7/22 and this care plan was initiated at that time.) On 10/12/22 at 11:50 AM, Surveyor interviewed NCC C (Nurse Care Coordinator) regarding R1's care plan. Surveyor asked NCC C what she is responsible for in her position regarding care plans. NCC C indicated, I do an MDS quarterly, so I update the care plans quarterly. My responsibility is if they have an incident then I go back and update for like a fall or skin. Generally anything with a behavior is updated by the Social Worker, dietary is done by the dietician, same for activities. R2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .R2's Quarterly MDS (Minimum Data Set) assessment, on 7/12/22, indicates that a BIMS (Brief Interview of Mental Status) should not be completed, indicating the resident is rarely/never understood. R2's record review did not indicate in the Comprehensive Care Plan interventions for a stop sign on her door, mothering interventions, increased supervision for protecting the resident from a known behavior of interacting with another male resident. On 10/12/22 at 11:27 AM, Surveyor interviewed CNA K (Certified Nursing Assistant). Surveyor asked CNA K if R2 ever had a stop sign on her door, CNA K replied periodically, but R2 always roamed the hallways, we wanted to just take it down. Surveyor asked CNA K how long the stop sign was in place for R2, CNA K replied about a month when I first came up here a year ago. It was up a year ago, then it has been down since, it was there to keep the roamers out of the room. On 10/12/22 at 1:24 PM, Surveyor interviewed NCC C and asked if she knew when the stop sign for R2's door was originally put in place. NCC C indicated, she did not. Surveyor asked NCC C if she knew why the stop sign interventions was put into place originally for R1's care plan. NCC C indicated, she would look in the computer. Of note, no further information was provided to Surveyor. Misconduct Incident Report dated 5/8/22, states, in part, Nursing Home Investigation Summary- R1 was witnessed extending arm and pushing R2 in the chest. Resident to Resident altercation reported and witnessed by RN M (Registered Nurse) . R1 stated R2 was following him and grabbing at him; so, he extended his arm and pushed her away. RN M reported residents were facing each other both seated in wheelchair when she saw R1 strike out and make a connection with R2's right chest area. Per social worker both residents have severe cognitive impairment. R1 is known to sleep in his wheelchair looking uncomfortable which R2 then gets concerned and tries to help him. Residents are known to follow each other at times. CNA K (Certified Nursing Assistant) indicates that prior in the shift that behaviors and interactions of both residents was not negative. R2 had not been bothering R1 as much as normal . Conclusion- Upon investigation and examination of resident-to-resident altercation. There was no intent to hurt R2. R1 was trying to get her to stop following and grabbing him. There is no apparent injury; both residents state yes to feeling safe at (facility). Staff followed proper procedure by separating residents and it has been noted with continuing monitoring, that residents are in separate common areas. Care plans are in place. Residents involved continues to feel safe at (facility), continues with daily routines without further injury. Progress/Behavior Notes from R1's chart: On 5/22/22 at 10:14 PM, Resident was thinking that CNA was his girlfriend. He would hold on to her arm tight and not let go. This writer went in room then resident let go of her and did hug with this writer trying to touch breast. I did slip out of his hold he did not touch breast. Resident laughing told CNA he was to kill staff . On 5/23/22 at 10:37 PM, .Resident did try to grab out at me but kept my distance, I did not have to do direct hygiene cares. Gave meds then he was reaching out to grab on to me but stretched my arm out when giving meds. On 6/16/22 at 9:59 PM, Resident got up out of w/c in dining room and walked to his room and sat in his recliner .we then toileted him, resident was trying to grab at our private areas of body. He was told we are his nursing staff and it's not appropriate . On 7/31/22 at 10:29 PM, .When doing peri care resident grabbing at this nurse. He was told not appropriate. When repositioning in bed resident keep trying to pull me in bed. I told him I was his nurse, he said no I'm his girlfriend. I did call in other staff member in room for some support. Other staff stood by him till he was ready to lay himself down . On 8/1/22 at 10:40 PM, .Resident very active this pm. He was hugging and saying he loves staff. Staff redirecting him as needed. On 9/12/22 at 10:50 PM, .after supper and HS resident wanting female staff to be very close to him. He was redirected, intervention effective. Misconduct Incident Report dated 9/14/22, states, in part, briefly describe the incident: R1 was found by staff member to be standing beside R2's bed with his pants down while R2 was in bed. He had R2's hand under his on top of his genitals. Nursing Home Investigation Summary states, in part; Summary of Events- CNA E was walking down the hall after providing care to another resident when she noted the call light was on and door closed for R2. She entered the room seeing R1 standing next to R2's bed with his pants down and his hand over R2's on his genitals. CNA E called for nurse during which time R1 pulled up his pants and was walking out of the room. R1 was then placed in his wheelchair and removed from the room into the hallway. CNA E went up to nurses' station to make a report at which time R1 was noted to by trying to again entry [sic] into R2's room. R1 was then taken to his room at which time CNA E again went back to the nurse's station to get Stop Sign to place across R2's doorway . Conclusion- It was concluded that R1 did inappropriately touch R2. Staff acted appropriately once the situation was identified making sure that R2 was safe and other residents on the unit were protected from possible harm. Physicians were notified to assess for medical causes and mental health was contacted regarding mental health causes. R1's care plan has been updated to reflect monitoring interaction with female residents and staff for any sexually inappropriate behaviors or interactions. R2 was moved off the same unit as R1 and is enjoying new placement. On 9/15/22 at 5:29 PM, (Physician/Nurse Practitioner Contact)- Writer contacted Nurse Practitioner . informing them of R1's behavior last pm shift and his inappropriate action. Nurse Practitioner stated that she feels this is a progression of his [CONDITION(S)] disease and that his behaviors have been changing. R1 has been looking at this other resident as if there was a relationship and the other resident was more interested in mothering him. Staff has been taking more time with R1 because of his impulsive behaviors and he has been defiant with staff when they are providing cares. Medical Doctor has made a change in his medication due to the reports of R1 is displaying more sadness as well. [CONDITION(S)] can bring on some depressions and Medical Doctor would like to control this before it becomes a worse issue for R1. Administrator has discussed issue with family and plans are being made to place R1 on a different unit. Currently, we have a 1:1 with him and he is enjoying the personal attention. On 9/15/22 at 5:43 PM, (Family/Guardian Contact): Situation: R1 seen leaning over another resident's bed with his hand on her hand touching his genitals. Background: . Past reports of pursing resident R2. This is the second time he has been seen disrobing in her room. Past efforts to provide line-of-sight supervision have not proven sufficient. Assessment/Action: R1 cannot safely stay on the same unit as R2. Will be moving R1 to another unit. View Recommendation/Request All parties in agreement. R1 will be moved 9/16 and has a 1:1 until that time. R1's progress notes dated 9/16/22 at 10:43 AM state in part; Staff has been assigned to monitor R1's behavior and his location at all times while on this unit and during our investigation. Plan has been made and it is agreeable to make a move for the other resident that is involved in this issue as it will be a positive move for her. No adverse behaviors have been noted for the resident yesterday or from this morning. R1's progress notes dated 9/20/22 at 10:38 PM, Resident did not believe this writer his nurse and wanting to kiss. When I showed him my name tag, he said it was fake. When staff toileting him he was grabbing at one CNA breast, resident redirected it was effective . R1's progress notes dated 9/21/22 at 10:41 PM, Resident wanting to hug and kiss, he was redirected with other thoughts, when told we do not do that here, not appropriate, he told this writer people have sex here all the time. This writer informed him that this is nursing home, that resident is not having sex all the time. Subject changed. On 10/11/22 at 11:47 AM, Surveyor interviewed CNA E (Certified Nursing Assistant), via telephone and asked what she recalled of the incident with R1 and R2 on 9/14/22. CNA E indicated, I was walking back to the nurse's station from another resident's room, I saw the light going off on R2's room and the door was shut. I knew she was someone who wandered, so I quickly went in to check on her and when I walked in R1's wheelchair was toward the bathroom, and he was on the bed. Surveyor asked CNA E, how R1 was on the bed? CNA E indicated, R2 was laying down on her back and R1 was sitting on the bed leaning on top of her. Surveyor asked if R1's body was kind of twisted. CNA E indicated, yes. Surveyor asked if R1 was leaning over R2 as he was twisted. CNA E indicated, yeah, so he was kind of leaning on her and he was holding her hand down on his private area and then with his other hand her night gown was lifted up and his hand was over her private area. I think he was trying to take her brief off. Surveyor asked CNA E if R2's brief was still on when she found them. CNA E indicated, yes, it was loose, but the tabs were still on. Surveyor asked, was his hand on top of the brief. CNA E indicated, yes, after I walked in, I realized what was going on and I turned and yelled for the nurse. CNA E continued, after I came into the room, he had his brief and his pants down past his knees kind of pooling around his ankle. I told him that this was not his room, and I grabbed the wheelchair and he had already started pulling his brief and pants up but was still sitting on the bed. As he was pulling his brief up, I turned toward the door I called for the nurse and when I looked back into the room after yelling for the nurse, he had already stood and was finishing pulling up his pants and brief and starting to walk out and then I grabbed the wheelchair and then in the hallway the nurse had him sit down. I had gone back into the room to check on R2 and she was pulling her nightgown down and I would say she was half asleep. Surveyor asked CNA E, what was being done to ensure R1 did not get back into R2's or other resident rooms. CNA E indicated, we had taken R1 to the nurse's station and we had him sit there with another nurse or CNA or I don't remember, maybe a RA (Resident Assistant). We always had someone try to keep an eye on him, because after this happened, he tried to go back in R2's room again. Surveyor asked if anyone took R1 to his room after the incident. CNA E indicated, someone tried that, but he got out and tried to go back to R2's room, so after that we had to have someone following him and keeping an eye on him. Surveyor asked CNA E, if someone was 1:1 with him. CNA E stated I do believe so. Surveyor asked CNA E if she knew who that was. CNA E indicated, I believe it was the nurse, I don't remember her name. Surveyor reviewed the nurses schedule from the date and time of incident with CNA E and asked if she could recall which nurse. CNA E indicated; I believe it was LPN F (Licensed Practical Nurse). Surveyor asked CNA E, when R1 attempted to go back to R2's room, who saw that and intervened. CNA E indicated, I saw it, because I was down that hallway and I was still putting people to bed. I had put a stop sign on R2's door. Surveyor asked CNA E, when you saw him outside of R2's room, was anyone else in the hallway. CNA E indicated, LPN F was passing meds in the hallway, she was at her cart. Surveyor asked CNA E if she recalled LPN F doing anything to intervene. CNA E indicated; I honestly don't know. Surveyor asked CNA E, when the stop sign was put up in front of R2's door. CNA E indicated; I want to say that was right away. Surveyor asked CNA E, when you saw R1 come out of his room was he going towards R2's room. CNA E indicated, well he was in his wheelchair, and he was sitting outside R2's room. Surveyor asked CNA E, did he get to R2's room before anyone saw him? CNA E indicated, yes, so I took him to the nurses' station and told LPN F and she said were just going to have to keep an eye on him. He did not want to stay in his room. Surveyor asked CNA E, if there has ever been an incident with R1 and inappropriate sexual behavior prior to this? CNA E indicated, I know there have been incidents with him and other residents, I can't go into detail because I wasn't there, but I have heard about it. Surveyor asked CNA E if any education regarding abuse had been completed with her after the incident. CNA E indicate, no. On 10/11/22 at 11:03AM, Surveyor interviewed LPN F via telephone and asked what she recalled about the incident on 9/14/22 between R1 and R2. LPN F indicated, I was standing at the med cart and one of the CNA's popped her head out of the door and yelled down for me to come down to the room, as I was walking down to the room R1 was walking out of the room. The CNA then reported what she saw. First, we got R1 into his wheelchair so then I had the CNA take him back to his room and I went in and talked to R2 as much as I could, and I just asked her yes or no questions because she can't describe things well. I asked her what happened and she kind of just looked at me. I asked if she felt safe, and she nodded yes. I asked if I could check her over. Her gown was down, her brief was in place, like it would normally be, I didn't notice anything on her skin. I asked her if she felt safe, nodded head yes. I asked if she knew what happened. R2 couldn't tell me what happened and then she just went right back to bed. Next, we made sure that R1 was in his room and then I called the supervisor and got a stop sign for R2's door and called NHA A. At that point I just needed more guidance because it was the first time I had dealt with that type of allegation. I got the paperwork going to get witness statement from the CNA. So, that was like bedtime, at that point we kept the stop sign on R2's door and we kept R1 in his room and I stayed between the two areas so I could keep an eye out to be sure he didn't go back in R2's room. I was at my cart doing my charting. Surveyor asked LPN F, if she ever left her cart during that time. LPN F indicated, that was pretty late, there was another nurse that came in to help me finish meds, because I got behind. I think it was LPN G, it was either me or her watching and we also had the CNA, so we were tag teaming to make sure they were separated. Surveyor asked LPN F if R1 ever came out of his room that night. LPN F indicated, he kept peeking his head out of his room, but didn't come out into the hallway. Surveyor asked LPN F if there has ever been an incident with R1 and inappropriate sexual behavior prior to this. LPN F indicated; I can't recall a time when this has happened before with him. Surveyor asked LPN F if R1 had inappropriate behaviors towards staff members. LPN F indicated, not while I was working, but I guess I can't say because it's never happened on my shift. I know there were CNA's that said he had made inappropriate sexual statements in the past. Surveyor asked LPN F if she was given any education regarding abuse after the incident. LPN F indicated; she received no education after the incident. LPN F indicated, usually it pops up in the system. In ECS (The facility's electronic health record) it will pop up to remind us to do education with the staff that are working. Surveyor asked LPN F, if it normally alerts you to perform education with the staff, then who educates the nurses when these incidents happen. LPN F indicated, Right. On 10/11/22 at 2:22 PM, Surveyor interviewed LPN G via telephone and asked what she could recall regarding the incident with R1 and R2 on 9/14/22. LPN G indicated she was told in report that one of the CNA's walked past and saw R1 in R2's room and went and got the nurse. I'm not sure who the nurse was that night, I don't recall. She went in and separated them and got him out of there and then they called NHA A (Nursing Home Administrator), and they also called R2's daughter, who is the Social Worker, and they were told to keep them apart. Surveyor asked LPN G, what things were done to ensure R2 and other residents' safety. LPN G indicated; we did frequent checks on R2. Surveyor asked LPN G what was meant by frequent checks. LPN G indicated, every 10-15 minutes we were checking on R1 to be sure he was still in bed. Probably more frequently because we are constantly walking up and down the hall because of call lights going off and just checking on things and making sure everyone is safe. Surveyor asked LPN G, what time did your shift start. LPN G indicated, I come in at 8:30, but I wasn't on that hall, I was on a different side of the building until 10:30 PM. Surveyor asked LPN G, what time she leaves in the morning. LPN G indicated, my shift is over at 7AM. Surveyor asked LPN G if she recalled if R1 came out of his room or attempted to come out of his room during her shift. LPN G indicated, I don't think so, but sometimes they will get him up if he is trying to crawl out of bed, I don't recall if they did that on that morning. They will get him up and put him by the nurse's station. Surveyor asked LPN G if R1 stays there or if he self-propels around the unit. LPN G indicated, no, he usually stays because all the aides are coming in and so he usually stays there and watches what is going on. Surveyor asked LPN G if she went over to the unit with R1 and R2 before 10:30 PM. LPN G indicated, yeah, I do go over there and help frequently. I did go over there before 10:30 PM that night, I didn't stay over there, but I went to help the nurse, can't remember her name. Surveyor reviewed the nurses schedule from the date and time of the incident and asked LPN G if LPN F was the nurse. LPN G indicated, well, when I came in, someone said to me that there was something going on over there and I should go see if she needed help and so I did. She didn't know exactly what to do with paperwork, so I called NHA A for her and then gave her the information NHA A told me. Surveyor asked LPN G what information NHA A provided to her. LPN G indicated, she told us what paperwork she wanted us to do and that she would do the rest of the paperwork in the morning. Surveyor asked LPN G if she shared with NHA A what they were doing to keep the other residents safe. LPN G indicated, yes. Surveyor asked LPN G if NHA A offered any further advice. LPN G indicated, no. Surveyor asked LPN G if they were keeping R1 in line of site or 1:1. LPN G indicated, he was already in bed sleeping when I got over there. Surveyor asked LPN G, were you just checking on R1 then and not line of site or 1:1. LPN G indicated, yes. Surveyor asked LPN G if she was aware of R1 coming out of his room after the initial incident. LPN G indicated, no, no one mentioned it to me. Surveyor asked LPN G if she was aware of any other behaviors like this with R1 and any other staff or residents and when? LPN G indicated, not that I'm aware of. I do know that he would tell some staff members that they were his girlfriend or wife, but I don't remember him ever physically touching anybody. Surveyor asked LPN G if she gave the CNA's guidance that night. LPN G indicated, yeah, the night shift CNA was there when it happened, so just keep a close eye on him and go by his room every 10-15 minutes. Surveyor asked LPN G if she received any education regarding abuse after this incident. LPN G indicated, no. On 10/11/22 at 4:15PM, Surveyor interviewed LPN H and asked what behaviors R1 is monitored for. LPN H indicated, suspicious, paranoid, sexual, independent because he likes to self-transfer and self-ambulate. Surveyor asked LPN H how long they have been monitoring for sexual behaviors. LPN H indicated, years. LPN H indicated R1 likes hugs; he'll say you're my girlfriend and I love you; he will try to pull you in bed with him when you do cares, and I'll tell him I'm your nurse and show him my badge and he will say that's not real. Surveyor asked LPN H how often these behaviors happen. LPN H indicated, maybe 2-3 times a week. LPN H indicated, we redirect him, keep our distance, change the subject, talk about something else, like football or wrestling because he likes watching wrestling. Give him a back rub with his lotion because he like that. Surveyor asked LPN H if she noticed those kinds of behaviors with other residents. LPN H indicated, yeah, with R2. Surveyor asked if there were any other residents. LPH H indicated, no other residents since R2, but R2 used to go to him for starters and touch his arm and touch him. LPN H indicated, before R2 was moved, we would put R1 in his room and R2 would try to go into his room. R2 would go down his hall and knew where his room was. R1 would just go up and down the center hall and just look at R2. LPN H indicated, a year and a half ago R1 went into R2's room and was in her recliner, just sitting there, we put a stop sign up and that stopped. R1 didn't pursue R2, it was usually the other way around. Surveyor asked LPN H, if she knew when they stopped using the stop sign. LPN H indicated; I don't think we ever did. On 10/11/22 at 4:29 PM, Surveyor interviewed CNA I and asked what behaviors R1 is monitored for. CNA I indicated, he gets upset about things; sometimes he's a little friendly; we have to watch him because he wants to be independent and tries to self-transfer and self-ambulate. Surveyor asked CNA I what she meant by he's a little friendly. CNA I indicated, he may want to hug you, hold your hand, maybe tell you that he loves you. Surveyor asked CNA I, if R1 does that with staff and residents. CNA I indicated, R1 has been known to do that with staff and occasionally with a resident. Surveyor asked CNA I, what kinds of things she has seen between R1 and R2. CNA I indicated, things like hold hands. I think one time I saw R2 had her hand on R1's leg, but nothing more, we would intervene, and someone would take R1 and someone else would take R2 and we would separate them. Surveyor asked CNA I what type of interventions are done when R1 is having behaviors. CNA I indicated, remove him from the area, bring him into his room, talk to him, give him a snack, maybe see if he wants to watch TV, take him to the restroom, and other things we can get him interested in. We try to check him frequently. Surveyor asked CNA I what frequently meant. CNA I indicated, we just try to keep a good eye on him and monitor him. If we have an RA (Resident Assistant) they are with him, and we have him in activities. Surveyor asked CNA I, which residents R1 has been friendly with. CNA I indicated, there was a lady, R2, I think she was moved to a different unit. Surveyor asked CNA I, how often do [TRUNCATED]

Based on interviews, observation and record review, the facility did not ensure that 1 of 2 residents (R6) reviewed with a [MEDICAL CONDITION] received complete orders and supplies for treatment including requirements for emergency care with prepared nursing staff. R6 was admitted with a [MEDICAL CONDITION]. The facility admitted R6 without ensuring that all nurses were trained in caring for a resident with a [MEDICAL CONDITION], without developing an emergency plan, and without assuring that all the proper equipment was readily available in R6's room to be used in an emergent situation. The facility's failure to ensure that staff had the correct procedure to follow and equipment readily available including the obturator and [MEDICAL CONDITION] at bedside to respond to an emergency and knew how to respond in an emergency created a finding of immediate jeopardy. Immediate jeopardy began on [DATE]. The NHA was notified on [DATE] at 12:00 PM, that immediate jeopardy existed. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for harm that is not immediate jeopardy/isolated) as all portions of the corrective actions have not been fully implemented. This is evidenced by: The University of Pittsburgh Medical Center's guide for [MEDICAL CONDITION] care, dated 2007, If your [MEDICAL CONDITION] comes out or becomes blocked, you need to have a plan to deal with the emergency situation quickly. If you are unable to solve the problem quickly, call 911. If the [MEDICAL CONDITION] comes out and another tube is not available. The stoma (neck opening) may stay open for a short period of time. 1. If possible, reinsert the old [MEDICAL CONDITION]. 2. If you cannot insert the old one, insert and hold a hollow tube such as a straw, suction catheter, or inner cannula into the stoma. Sometimes the smaller inner cannula can be inserted until emergency help arrives. 3. If using a straw, suction catheter, or inner cannula, replace with a new [MEDICAL CONDITION] or old [MEDICAL CONDITION] as soon as possible. Emergency kit should include the following supplies: A clean [MEDICAL CONDITION] set with obturator, water soluble lubricant, such as [MEDICATION NAME], suction catheter, syringe, if you have a cuffed [MEDICAL CONDITION], sterile saline bullets, gloves, [MEDICAL CONDITION] ties, a smaller size [MEDICAL CONDITION] set with obturator. Remember to make an emergency plan. The facility follows the SMS (specialized medical services) guidelines undated, for [MEDICAL CONDITION] care which include in part; Always have experienced caregiver when administering [MEDICAL CONDITION] care. Emergency tube replacement: Maintain sterile tracheal [MEDICATION NAME] or hemostat. Sterile obturator that fits the [MEDICAL CONDITION] in use. Spare [MEDICAL CONDITION] and obturator. Suction equipment and supplies. Resuscitation bag. Call 911 if unable to reestablish airway. Always have a back-up [MEDICAL CONDITION] available in the facility. R6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R6 had a cuffed #6 Shiley [MEDICAL CONDITION] surgically placed on [DATE], and the [MEDICAL CONDITION] was replaced on [DATE] with a # 6(NAME)(metal) trach. R6 did not have an MDS (Minimum Data Set) competed at time of survey but is alert and oriented x 3 which indicates R6 is cognitively intact. R6's discharge orders indicate that he was full code status in the event of a cardio [MEDICAL CONDITION] arrest upon admission. R6's Comprehensive care plan dated [DATE] includes in part: Problem (Post surgery): Potential for post-surgical complications related to [MEDICAL CONDITION] place. Goal: Will maintain pulse oxygen above 88% on RA (room air). Approach: Assess for signs of infection, assess for pain per protocol, encourage deep breathing and coughing. Encourage mobility - suctioning machine and 02 (oxygen) concentrator in room. Nurse aide- Report pain indicators. Report changes in ability. Encourage deep breaths. To be noted, R6's care plan does not [MEDICAL CONDITION] including the type and size of the trach, suctioning, capping the stoma or what to do in an emergency situation if [MEDICAL CONDITION] plugged, dislodged or decanulated. R6's discharge instructions include in part: R6 will have a [MEDICAL CONDITION] in place on discharge as well as a [DEVICE] for continues tube feeding. Have [MEDICAL CONDITION] available at all times. R6 will require skilled nursing on discharge for continued trach, tube feeding cares, and teaching. R6 will require the following supplies which include in part; 1) Heated home humidification [MEDICAL CONDITION]. 2)[MEDICAL CONDITION] kits [MEDICAL CONDITION]. R6's Physicians Orders includes in part; Respiratory treatment: clean neck with soap and water, dry thoroughly daily. [MEDICAL CONDITION] 5 ml (milliliters of saline every 8 hours and prn (as necessary). To be noted, R6's physician's orders [REDACTED]. R6's Physician order [REDACTED]. R6's Treatment Administration Record (TAR) includes in part; May use ice over cloth barrier to neck 20 minutes on and 20 minutes off as needed for [MEDICAL CONDITION] (swelling). On [DATE] at 1:40 PM Surveyor observed sitting in his wheel chair while receiving a tube feeding. R6 was noted to have a [MEDICAL CONDITION] (opening in the trachea to maintain an airway). Surveyor did not observe an obturator (instrument used to insert a [MEDICAL CONDITION]) or an [MEDICAL CONDITION] visible at bedside. On [DATE] at 2:15 PM Surveyor asked Registered Nurse (RN) H if she could show Surveyor R6'[MEDICAL CONDITION]. RN H indicated she had to give another resident a medication and could show Surveyor in a few minutes. Surveyor agreed and observed R6's medical record at the nursing station waiting for RN H. DON B entered the medication room where RN H was looking through supplies. On [DATE] at 2:25 PM, Surveyor observed DON B enter R6's room. Surveyor knocked and entered R6's room as DON B was looking in R6's cabinets. Surveyor asked DON B to show Surveyor where the [MEDICAL CONDITION] are located. DON B opened the cabinet and removed a few boxes and Surveyor observed extra tube feeding supplies and [MEDICAL CONDITION] and saline. Surveyor asked DON B where R6's obturator is located. DON B indicated that R6 will only have [MEDICAL CONDITION] a week. DON B continued to search in drawers for the obturator. DON B indicated that [MEDICAL CONDITION] been coming out. Surveyor asked DON B what the facility does when [MEDICAL CONDITION] to become dislodged. DON B indicated that when [MEDICAL CONDITION] to come out, the facility will lay R6 down, clean around it and push it back in. DON B again indicated that [MEDICAL CONDITION] temporary and will come out in a week or so. Surveyor asked DON B what the facility process is if [MEDICAL CONDITION] be dislodged completely. DON B indicated that they would call the Medical Doctor (MD) and question if they should just leave it out. Surveyor asked DON B if there should be an obturator in the room and extra trach. DON B indicated that there should be. DON B indicated that there was not an obturator and it would be metal if he had one. DON B indicated that this is not a matter of life or death. On [DATE] at 2:40 PM, Surveyor observed DON B and RN C looking in R6's drawers and cabinets. Surveyor asked RN C if she knew where the obturator was and an extra trach. RN C indicated that she thought she may have seen the obturator when R6 was admitted . RN C indicated that she did not know where it went. Surveyor asked RN C if the obturator might be located in the drawer below the suction machine. RN C opened the drawer and found a specimen container with a lid and observed an obturator in the container. DON B indicated that R6'[MEDICAL CONDITION] supposed to come out. On [DATE] at 3:13 PM, Surveyor interviewed Licensed Practical Nurse (LPN) N regarding the education she has received on [MEDICAL CONDITION] care at the facility prior to R6's admission. LPN N indicated that she has not had to deal with trachs since nursing school and would have to call a supervisor as she has not had any training. On [DATE] at 3:17 PM, Surveyor interviewed RN O [MEDICAL CONDITION] and what to do in [MEDICAL CONDITION]. RN O indicated that she would get something in there for an airway, call 911. RN O indicated that the facility does not have any cannulas sitting around. Surveyor asked RN O what an obturator is used for. RN O indicated that she did know what that was and asked Surveyor what is that? RN O indicated that she provides [MEDICAL CONDITION] to the staff if needed. RN O indicated that she does not train nurses on the obturator as she does not know what that is. On [DATE] at 3:20 PM, Surveyor interviewed RN F [MEDICAL CONDITION] and when the last time she had [MEDICAL CONDITION] education at the facility. RN F indicated that she did not recall when the facility had any [MEDICAL CONDITION] education. On [DATE] at 3:30 PM, Surveyor interviewed LPN L regarding the obturator and what it is used for. LPN L stated that she didn't know what it was. LPN L indicated that she had training maybe last year. On [DATE] at 3:44 PM, Surveyor interviewed RN H [MEDICAL CONDITION] and when the last time she had [MEDICAL CONDITION] education at the facility. RN H indicated that she has not had [MEDICAL CONDITION] at the facility. RN H indicated that the [MEDICAL CONDITION] she had received was in nursing school. RN H indicated she has worked here almost 2 years. On [DATE] at 3:46 PM, Surveyor interviewed RN C [MEDICAL CONDITION] and when the last time she had [MEDICAL CONDITION] education at the facility. RN C indicated to Surveyor that she has not had [MEDICAL CONDITION] at the facility since she has worked here. On [DATE] at 4:00 PM, Surveyor interviewed DON B regarding the education provided to staff on [MEDICAL CONDITION] care. DON B indicated that she has been with the facility since ,[DATE] and she did not know if the facility has provided [MEDICAL CONDITION] education/ in servicing. DON B indicated she would check and get back to Surveyor. DON B indicated that she has a [MEDICAL CONDITION] education and oxygen education in-service scheduled for next month. DON B gave Surveyor a copy of the SMS manual [MEDICAL CONDITION]. DON B indicated that a copy of the SMS was at the nurse's station but RN C was not aware of that. Surveyor asked DON B if the facility has an ambu bag. DON B indicated that each medication room has an ambu bag. DON B also indicated that each nurse is CPR certified. DON B indicated that most definitely the nurses should be able to manage a [MEDICAL CONDITION]. DON B indicated the RN G educated RN C. Surveyor asked for documentation of the education provided to RN C. On [DATE] at 5:25 PM, Surveyor interviewed RN C regarding the size of the obturator for R6. RN C and RN S entered R6's room and removed the container with the obturator. RN C brought it to the nurse's station and removed the cover. RN C and RN S looked at the obturator and RN C stated, It is either a 9 or a 6, it looks like a 6. On [DATE] at 5:30 PM, Surveyor interviewed RN S regarding when she last had [MEDICAL CONDITION] training. RN S indicated that it was a long time ago. Maybe ,[DATE] years ago. On [DATE] at 8:10 AM, Surveyor asked RN T regarding the education she has received [MEDICAL CONDITION] prior to [DATE]. RN T indicated that RN U verbally explained how to do it. RN T indicated that it was not a hands on demonstration. Surveyor asked RN T what she would do if R6 became pulseless / or non- breathing. RN T went to the medication room on the 1st floor and showed Surveyor the ambu bag. Surveyor asked RN T how she would use it with R6. RN T indicated that the attachment would be fitted onto the ambu bag. RN T showed Surveyor a sealed plastic bag that contained 2 plastics pieces and a blue ribbed plastic tube. RN T attempted to connect the plastic parts to the ambu bag without success. RN T removed all of the pieces from the plastic bag and attempted to attach them to the ambu bag without success. RN T indicated she does not know how this works and would need training. On [DATE] at 8:15 AM, Unit Clerk (UC) V came into the medication room and indicated that the ambu bag should be standard and fit the opening of the trach. UC V indicated that she is also an EMT (emergency medical technician) and indicated the plastic parts that were in the container with the ambu bag are in case a resident needs a nebulizer treatment (aerosol medication) at the same time while being bagged (rescues breaths by ambu bag). Surveyor asked UC V when she last [MEDICAL CONDITION] at the facility and UC V indicated that [MEDICAL CONDITION] is from being an EMT. On [DATE] at 9:00 AM, Surveyor interviewed RN F regarding [MEDICAL CONDITION] she received before starting her shift today. RN F indicated that she did not have [MEDICAL CONDITION] and it was a couple of years since she did. RN F indicated that she was to attend an in-service but was unable to attend as she had a resident to 2011 Wisconsin Code Chapter 154. Advance directives. 154.19 Do- not- resuscitate order. States in part, 154.19 (1) No person except an attending physician may issue a do- not- resuscitate order. 154.19 (c) The order is in writing. care for. On [DATE] at 9:20 AM, Surveyor interviewed LPN D regarding the process if R6 coded. LPN D indicated she would get the ambu bag but wanted to review the policy before answering any more questions. LPN D indicated there should be an adaptor for the ambu bag. LPN D indicated she had [MEDICAL CONDITION] this morning but would prefer to look at the policy. On [DATE] at 9:22 AM, Surveyor interviewed RN E regarding [MEDICAL CONDITION] she received before starting her shift today. RN E indicated that she did not have [MEDICAL CONDITION] or re - education. On [DATE] at 9:25 AM, Surveyor interviewed LPN M regarding the education she has received on trachs. LPN M indicated that she has not had any experience with trachs. LPN M indicated she has not worked with any at this facility and does not have any on her unit. LPN M indicated there is some kind of attachment but does not know the name of it. On [DATE] at 9:30 AM, Surveyor asked DON B if the facility has had any mock code drills or any documented [MEDICAL CONDITION] education prior to [DATE]. DON B indicted no and could not provide any [MEDICAL CONDITION] education. On [DATE] at 9:40 AM, Surveyor interviewed RN G regarding R6's documentation for [MEDICAL CONDITION] capping. RN G indicated that she called the clinic the day after admission. RN G indicated the company that brought R6's equipment said to uncap [MEDICAL CONDITION] night and use the humidity. RN G indicated she questioned that as the nurse from the hospital said R6 was capped 24 hours a day at the hospital. RN G indicated she spoke to RN Q and the goal is to get [MEDICAL CONDITION] in 2 weeks. RN G indicated the facility was to cap [MEDICAL CONDITION] much as possible. Surveyor asked to see the MD orders for capping the [MEDICAL CONDITION] and the progress note regarding R6's [MEDICAL CONDITION] documenting the plan to remove it. RN G indicated that the capping is not on the MD orders, TAR or Medication Administration Record [REDACTED]. RN G indicated no, but has appointment scheduled and it is on a sheet of paper in R6's room. RN G indicated that Family Member (FM) P changed some of the appointments to coordinate in one day. Surveyor asked RN G where the documentation is from the phone call to the hospital with RN Q. RN G indicated she did not document either of the conversations. On [DATE] at 4:30 PM Surveyor observed R6 sitting in his wheel chair in his room coughing with secretions coming out of his [MEDICAL CONDITION]. R6 was gasping for air as he was coughing. R6 was spitting onto a towel over his tray table while leaning forward. Surveyor immediately notified RN C who was R6's nurse that shift. On [DATE] at 4:00 PM, Surveyor reviewed R6's medical record and observed the Resident Advanced Directive Statement form dated [DATE], was signed by R6's bother. To be noted R6 is his own person. In the box where the choice is listed for CPR, yes and no are documented. The attending physician signature line was not signed. R6's nursing notes dated [DATE] at 4:38 PM, includes in part; Metal(NAME)[MEDICAL CONDITION] in place.[MEDICAL CONDITION] been capped ,[DATE] since [DATE] and tolerating well. Alert and oriented x 3. R6's nursing notes dated [DATE] at 11:08 PM, includes in part; Mucus white, frothy small amount. Suctioning provided. R6's nursing notes dated [DATE] at 1:59 AM, includes in part; [MEDICAL CONDITION], humidified air is provided. R6's nursing notes dated [DATE] at 1:00 PM, includes in part; spoke with MD's office for clarification on humidification with trach. Awaiting call back. To be noted; the clarification orders for the humidification was not documented until [DATE]. R6's nursing notes dated [DATE] at 2:07 AM, includes in part; suctioning provided, tolerating well, airway patent. R6's nursing notes dated [DATE] at 3:18 PM, includes in part; New orders received 3ml (milliliters) saljets (contains saline) [MEDICAL CONDITION]. R6's nursing notes dated [DATE] at 12:20 AM, includes in part; late entry for [DATE] without a time, held [MEDICATION NAME] suspension; R6 in breathing distress during attempts to administer oral swish med. R6's nursing notes dated [DATE] at 1:17 AM, includes in part; late entry for [DATE] PM shift, R6 has [MEDICAL CONDITION] in place, need for support and intervention to promote respiratory stability. Audible wheezing heard, congested, cough productive at times and dry at times. Encourage coughing and deep breathing, [MEDICAL CONDITION] cares provided with suctioning. R6's nursing notes dated [DATE] at 5:47 AM, includes in part; Respiratory findings: sudden onset: cough and wheezing at 11:45 PM, R6 had a spasmodic cough with clear to white mucous being coughed up. Cough continues and exacerbates [MEDICAL CONDITION]. Cough is intermittent for the next ,[DATE] hours with white, sometimes flecks of blood with mucous. Head of bed (hob) elevated. R6's nursing notes dated [DATE] at 12:05 PM, includes in part; Cough congested, thick productive thick white sputum from trach. R6's nursing notes dated [DATE] at 6:30 PM, includes in part; Mucus clear at first then turned frothy, cream colored. Lung sounds wheezing heard. Suctioning provided. Tolerated poorly. Coughed up some of his tube feeding fluid. Continued coughing with sputum produced. R6's nursing notes dated [DATE] at 11:21 PM, includes in part; Slight stridor noted, hob at 60 degrees. Wheezing heard, mucus, small amount, white thick. Has [MEDICAL CONDITION], suctioning provided. R6's nursing notes dated [DATE] at 1:00 AM, includes in part; Cough with some white to clear sputum. On room air (RA) [MEDICAL CONDITION] #6 metal without cuff. [MEDICAL CONDITION] R6 is receiving humidified air. HOB elevated. Continue to observe for changes in R6's respiratory status. R6's nursing notes dated [DATE] at 12:01 PM, includes in part; per RN G, Late entry for [DATE] at 4:00 PM. Physician contact: spoke with RN Q regarding the humidification for R6 and when [MEDICAL CONDITION] to be capped. Per RN Q in MD R's office. MD R wants [MEDICAL CONDITION] in two weeks. No need for humidity [MEDICAL CONDITION] capped. To be noted; there is no documentation that [MEDICAL CONDITION] to be removed or when R6'[MEDICAL CONDITION] been capped vs left open. R6's nursing notes dated [DATE] at 12:12 PM, includes in part; per RN G, late entry for [DATE] at 10:48 AM, spoke with RN Q regarding need for clarification. Per RN Q, they do not send home extra trachs when they discharge from the hospital. We are to reinsert the [MEDICAL CONDITION] it dislodges. R6 is to stay capped unless he is feeling distressed. We are to use a small mask and hold [MEDICAL CONDITION] get seal if R6 should need rescue breaths with ambu bag. Orders were written and faxed to MD R per RN Q's request. To be noted; there is no documentation or orders [MEDICAL CONDITION] care or capping until [DATE]. R6 was admitted on [DATE] with full code status. The above orders indicate that there is no need to use a connecting device with the ambu bag. R6's nursing notes dated [DATE] at 2:21 PM, includes in part; R6 tolerated suction without difficulty. R6's nursing notes dated [DATE] at 1:15 AM, includes in part; has moisture hood for respirations. Appliances: has [MEDICAL CONDITION]. R6 Physician's telephone orders dated [DATE] at 10:50 AM includes in part, Reinsert [MEDICAL CONDITION] it would come out. No need for [MEDICAL CONDITION] room. [MEDICAL CONDITION] as much as possible. May uncap if R6 feels in distress. If R6 would need rescue breaths use small O2 (oxygen) mask [MEDICAL CONDITION] hold for seal. Procedure [MEDICAL CONDITION]: clean trach, 1) Remove inner cannula. 2) Place obturator in trach. 3) Reinsert into stoma, curve shape of trach. 4) Pull obturator out. 5) Reinsert inner cannula. Make [MEDICAL CONDITION] are secure. Per RN Q. To be noted the facility did not have an emergency procedure in place if R6'[MEDICAL CONDITION] it would have dislodged prior to [DATE] at 10:50 AM. Despite facility knowledge that R6 was admitted with a [MEDICAL CONDITION] and was full code upon admission, the facility failed to assure that the necessary emergency procedures and supplies were readily available at R6's bedside. The facility had no evidence that any staff had [MEDICAL CONDITION] education prior to [DATE] and no evidence that all nursing staff was trained in emergency procedures for residents with tracheostomies. The facility's failure to have evidence of trained professional nurses in the facility with readily available equipment to be used in an emergency and its failure to assure that R6 would be provided with appropriate emergency medical assistance if his [MEDICAL CONDITION] airway became obstructed, dislodged, or decanulated created an immediate jeopardy situation. The facility removed the immediate jeopardy on [DATE] by taking the following actions: DON will provide education prior to work shift to Nurses, regarding the following: A)[MEDICAL CONDITION] and management of Trach. B) Replacing a Trach, inserting a smaller Trach. C) Use of Ambu bag for resuscitation for Residents with a Trach. (Proper adaptor). How to provide rescue breathing to someone with a Trach. D) What is an Obturator, how to use describe universal location for obturator. E) Clarification of Code Status immediately upon admission. DON will: A) Order [MEDICAL CONDITION]#6 B) Designate a universal location for the obturator. An audit will be conducted upon admission of residents with [MEDICAL CONDITION] for supplies extra trach, obturator, and all required supplies necessary. Summary of audit will be presented at QAA. DON will review and update as needed the following policies: Trach Care. Unit clerk X has ordered an [MEDICAL CONDITION]#6 for R6. Unit clerk X will order an obturator for R6.

Based on interview, observation and record review the facility did not ensure that the resident has the correct advanced directive and a signed physician order to honor his wishes for 1 of 21 residents reviewed (R6). R6's Hospital Discharge summary dated [DATE] indicated R6 was a full code. On admission, R6's son, FM P (Family Member) signed the facility's Resident Advanced Directive Statement form, dated [DATE], indicating R6 is a do not resuscitate (DNR). In the box where the choice is listed for cardio [MEDICAL CONDITION] resuscitation (CPR), both yes and no are documented, making it unclear what R6's wishes were. R6 had a red dot on his nameplate outside his door, indicating he was a DNR. However, R6 did not have a signed Physician's order for a DNR, which is required in Wisconsin if one does not want resuscitation. The failure to accurately identify R6's code status resulted in an Immediate Jeopardy to the health and safety of R6 who had the potential to be resuscitated or not to be resuscitated by staff against his expressed wishes in case of emergency. The Immediate Jeopardy began on [DATE]. The NHA (Nursing Home Administrator) was notified of the Immediate Jeopardy on [DATE] at 12:00 PM, The Immediate Jeopardy was removed on [DATE] at 12:55 PM. The non-compliance at F155 remains at scope and severity level of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to train staff as they report to work. This is evidenced by the following: According to a decision by the Division of Appeals Board, it is crucially important that nursing homes have in place policies and procedures designed to ensure that the wishes of their residents, both for DNR (do not resuscitate) and CPR (cardio-pulmonary resuscitation), are accurately recorded, made accessible, and implemented as desired by the residents. The facility's policy Advanced Directives dated ,[DATE], includes in part; An Advanced Directive describes, in writing, resident choices about the treatments they want or do not want, or about how health care decisions should be made for them if they become incapacitated and cannot express their own wishes. A resident's advances directives will be followed in accordance with state law and facility policy. Procedure: 3. upon admission the admitting nurse will review with the resident, legal guardian, health care agent, or representative preference for CPR. Complete the facility Resident Advance Directive Statement form and after the resident has been at the facility for 90 days or at which time the resident is deemed as long term care a Patient Advanced Care Orders (PACO) document will be completed replacing the Resident Advance Directive Statement form. 5. The Registered Nurse (RN) will notify the attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. On [DATE] at 1:40 PM Surveyor observed R6's name plate outside his door with a small red dot on it. R6 was observed sitting in his wheel chair while receiving a tube feeding. R6 was noted to have a [MEDICAL CONDITION] (opening in the trachea to maintain an airway). On [DATE] at 1:50 PM, Surveyor asked RN H what the red dot indicates on R6's name plate. RN H indicated the red dot means DNR. On [DATE] at 4:00 PM, Surveyor reviewed R6's medical record. R6's hospital discharge summary signed and dated [DATE], includes in part; Code status at discharge: Full. The Resident Advanced Directive Statement form, dated [DATE], was signed by R6's son, even though R6 is his own person. In the box where the choice is listed for CPR, both yes and no are documented. The attending physician signature line was not signed and there was no physician order for [REDACTED]. If R6 wanted to be DNR, he did not have a signed physician's order. On [DATE] at 4:00 PM, Surveyor interviewed Director of Nursing (DON) B regarding R6's code status. Surveyor showed DON B R6's Advanced Directive Statement form dated [DATE]. Surveyor asked DON B what R6's code status is based on this form. DON B noted the yes and no that was marked and stated, Good question. DON B indicated that she did not know what the code status is based on this form. Surveyor showed DON B the signed discharge summary that documented full code. DON B indicated R6 is a full code. Surveyor asked DON B if R6 should have a red dot on his name plate on the outside of his room. DON B indicated that R6 should not have a red dot on his name plate. On [DATE] at 5:25 PM, Surveyor interviewed RN C regarding R6's code status. RN C indicated R6 is a DNR and has a red dot on his name plate. Surveyor showed RN C R6's Advanced Directive Statement form dated [DATE]. Surveyor asked RN C what R6's code status is based on this form. RN C noted the yes and no that was marked and stated, Looks like they crossed it out. I would be in question. Should have initials and have been reviewed. Review of R6's Comprehensive Care Plan, dated [DATE] and [DATE], does not include code status. On [DATE] at 7:15 PM, NHA A gave Surveyor a copy of R6's Resident Advanced Directive Statement form dated [DATE] that now documents No in the box for CPR. To be noted, R6 signed this form but there is not a physician's signature on this form. On [DATE] at 11:20 AM, Surveyor reviewed R6's medical record and observed the Resident Advanced Directive Statement form that R6 signed last night now includes the Medical Director (MD) J signature dated [DATE]. Surveyor immediately went to R6's room and asked R6 if he was seen by a doctor today. R6 indicated no, he has not and pointed to the wall where lists of future appointments are posted. Surveyor asked R6 if his heart stopped beating would he want the facility to try to restart it. R6 indicated no. On [DATE] at 11:30 AM, Surveyor interviewed RN G regarding the physician that signed R6's advanced directive form. RN G indicated that MD J was in today and signed the form. Surveyor asked RN G if MD J was R6's primary physician. RN G indicated that MD J was not R6's primary physician. Surveyor asked RN G why MD J signed the form. RN G indicted she did not know. On [DATE] at 12:00 PM, RN G indicated that MD J did not see R6 today. Surveyor asked RN G how MD J knows for certain what R6's wishes are. RN G indicated MD J goes by what the nurse's document on the Advanced Directives form. On [DATE] at 4:35 PM, Surveyor interviewed Social Worker (SW) I regarding the facility process for obtaining code status. SW I indicated once the resident is admitted , the advanced directives form is filled out by nursing. SW I indicated it will be reviewed with the resident or family annually or sooner if needed. Surveyor asked SW I who signs the advanced directives form. SW I indicated the resident will or responsible party and the MD. Surveyor asked SW I when the MD is to sign the form. SW I indicated the MD will sign the form after speaking with the resident. Surveyor asked SW I if a MD should sign the advanced directives form without speaking the resident. SW I indicated, no, the MD should not sign the form without speaking to the resident and obtaining their actual wishes. To be noted, MD J is not R6's primary physician and he signed the advanced directives form without speaking to R6. The facility did not ensure R6's code status was accurate upon admission on [DATE], and this was not identified until questioned about R6's code status on [DATE]. R6 did not have an MD signature on his advanced directives until 6 days post admission. The facility did not have a valid DNR order for R6 until [DATE]. The failure to ensure that staff knew the advanced directives and the directives were accurately and consistently documented created a finding of immediate jeopardy. The Immediate Jeopardy was removed on [DATE] at 12:55 PM after the facility completed the following: NHA will coordinate a facility sweep immediately to audit: a) Advance Directive Form for competition. b) Residents who have made a DNR decision: 1) Red dot is on the chart. 2) Red dot is on the name plate. NHA will review and revise as needed the Admissions check off to add a double check of resident's choice and preference for code status. DON B will provide an in-service to the Social workers, Admission Nurse before their working shift. Education will include: A) Accuracy of code status. B) Double check process upon admission of code status. C) Obtaining the appropriate physicians orders for code status Revised Admission check off that adds this step. An audit will be conducted for all residents admitted checking for accurate code status. Audit will be completed by Admissions Nurse, Nurse Managers, and Social Workers. Summary of audit will be presented at QAA. DON will review and update the CPR Policy. DON will educate all nurses on CPR policy.

Based on observation, interview, and record review, the facility did not ensure that the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents and the Facility did not consistently implement new interventions to prevent falls when past interventions had proven ineffective for 1 (Resident 6) of 6 Residents reviewed for falls. Resident 6 had an un-witnessed fall on [DATE] resulting in an abrasion and bruise to her right elbow and a goose egg to the back of her head. Interventions of a bed alarm and 30 minute checks were put in place. Resident 6 had second unwitnessed fall was on [DATE]. Resident 6's Post Fall Report documents that the bed alarm was turned off and she had bare feet. Resident 6's fall resulted in an open laceration above her left eye and hip pain. Resident 6 was sent to the emergency room for sutures and evaluation of the hip pain. This is evidenced by the following: Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6's most recent quarterly Minimum Data Set, assessment reference date [DATE], includes the following: Brief Interview for Mental Status (BIMS) score = 15 indicating Resident 6's memory is intact. Section G0110 Activities of Daily Living (ADL) indicated that Resident 6 scored a ,[DATE] for transfers and ambulation which indicates that Resident 6 would be independent and require no staff assistance. Resident 6's Fall Risk assessment dated [DATE] scored a 7 which indicates that Resident 6 is not at risk for falls. Resident 6's Admission Care Area Assessment (CAA) for Falls [DATE], states in part, Medications: Antipsychotics, Description of problem: slight risk for falls with medication she takes and [DIAGNOSES REDACTED]. Resident 6's Comprehensive care plan for falls, dated [DATE], states in part, Potential for falls related to weakness from declining health, use of pain medication, blind in rt (Right) eye, uses walker. Nurse's provide non - skid footwear. Nurse Aide: encourage to ask for assistance. Call button in reach. Use assistive devices. Anticipate needs, mat to floor beside bed when in bed, gripper socks when in bed, ask for assist of 1 and pendent call light in use. Resident 6 had a fall on [DATE]. Resident 6's Post Fall Report states in part, On [DATE] at 3:25 AM, Resident 6 had an un-witnessed fall. Root cause: Refused to use her call light and call light pendant for assistance. Didn't use her wheelchair or walker when ambulating. Measures in place: Gripper socks call light and call pendant within reach of patient. New plan: Bed alarm and 30 minute checks. Resident 6's Comprehensive care plan for falls, dated [DATE], states in part, Potential for falls related to weakness from declining health, use of pain medication, blind in rt (Right) eye, uses walker. Nurse's provide non - skid footwear. Nurse Aide - encourage to ask for assistance. Call button in reach. Use assistive devices. Anticipate needs, mat to floor beside bed when in bed, gripper socks when in bed, ask for assist of 1, pendent call light in use. Pad alarm to bed and in recliner chair. Of note: the intervention on the Post Fall Report dated [DATE] includes 30 minute checks and this was not included on the care plan. Resident 6's nursing notes on [DATE] at 1: 55 AM, documented late entry for fall at 11:00 PM, includes: Fall related injury: Laceration above left eye compression and ice to laceration. Toileting self as bathroom door was open, soiled underwear on the floor next to the toilet, and resident had walked into neighbors rest room, fallen, bottom was soiled. Bed alarm was not sounding; all other alarms on the unit were on. Resident 6's alarm, question if resident turned it off as it was in reach. Laceration above left eye with significant amount of blood noted on the floor, some complaints of hip pain. Had bare feet, did not use her walker, and potentially turned off her alarm. Left pupil slightly larger than the right. IDT meeting states in part, We discussed potential of Res (Resident 6) shutting off alarm. Also it was noted she is to have gripper socks on at all times. Physician Telephone Orders unsigned and dated [DATE] include: Send to ER (emergency room ) for Eval (Evaluation) and Treat (Treatment). Review of ER notes [DATE] at 12:06 AM include: 1.5 cm (Centimeter) X 4 mm (Millimeters) over left eye, 4 sutures placed. Resident 6's Post Fall Report states in part, On [DATE] at 11:00 PM, Resident 6 had an un-witnessed fall. Root cause: Alarm was not sounding, feet were bare. Measures in place: Alarm- but turned off. Bed side mat. New plan: Clip alarm, move bed alarm control to other side of bed, 30 minute checks. The documentation does not mention any interventions regarding the gripper socks that were not on at the time of the fall. Resident 6's Guidelines For Daily Care with hand written Active CP (Care Plan) on [DATE], states in part, Special Instructions: Mat to floor when in bed. Bed in lowest position, gripper socks on at all times when in bed. Bed alarm in bed and when up in recliner chair. Of note: 30 minute checks are not on this documentation. Resident 6's Comprehensive care plan for falls, dated [DATE], states in part, Potential for falls related to weakness from declining health, use of pain medication, blind in rt (Right) eye, uses walker. Nurse's provide non - skid footwear. Nurse Aide - encourage to ask for assistance. Call button in reach. Use assistive devices. Anticipate needs mat to floor beside bed when in bed, gripper socks when in bed, ask for assist of 1 pendent call light in use. Pad alarm to bed and in recliner chair. 30 minute safety checks. Resident 6's Comprehensive care plan Self- care Deficit dated [DATE] states in part, Nurse Aide: Other special directions: Mat to floor when in bed. Bed in lowest position, gripper socks on at all times when in bed. Pad and clip alarm in bed and when up in recliner chair. 30 minute safety checks. I need one assist, with gait belt and walker when I am walking in the hall / long distances (due to increased weakness). Surveyor reviewed Resident 6's medical record and noted the following: 30 Minute Rounding Log dated [DATE]/ at 12:00AM through [DATE] at 2:30 PM when the IDT (Interdisciplinary Team) decided to stop the 30 minutes checks. The 30 minute checks resumed on [DATE] at 3:30 AM and continued [DATE] 11:30 PM. Of note: this documentation form does not include gripper socks/ nonskid footwear documentation. Resident 6's nursing notes on [DATE] at 3:32 AM, States in part, Res (Resident 6) returned to (Facility) via Transport Company on a cart. Gripper socks on feet, alarm on left side of bed. Of note: There is no documentation to indicate that Resident 6 has ever removed her gripper socks or turned off her bed alarm. On [DATE] at 9:30 AM, Surveyor observed Resident 6 sitting in her recliner on a sensor pad and noted that she had a very black and purple left eye with sutures in her left eyebrow. Surveyor asked Resident 6 what happened to her left eye. Resident 6 stated, I don't know. On [DATE] at 4:00 PM, Director of Nursing (DON) B indicated that she has 7 staff interview regarding Resident 6 and the gripper socks and gave them to Surveyor to indicate that she has been removing them. Certified Nursing Assistant (CNA) C's statement on [DATE] states, I have seen (Resident 6) take off her socks herself along with the rest of her clothing. She doesn't always ask for help. She does things for herself when she wants. She has told me she does not like to wear the gripper socks to bed. She self-transfers even when she feels weak or unsteady. She doesn't use her walker when she does self-transfer. The resident lately has become confused and forgetful. CNA D's statement on [DATE] states,{Resident 6} is very capable of removing gripper socks as well as picking up floor mat and putting it under bed. She self- transfers also, dresses and undresses herself. Very forgetful. CNA E's statement on [DATE] states, Resident 6 has been known on multiple occasions to take her gripper socks off by herself. She is on another occasion took her floor mat, folded it in half and put it underneath her bed. She self - transfers herself normally and will not ask for assistance. She is becoming more forgetful as to what she needs to do with cares or what she has already done. CNA F's statement on [DATE] states, Resident 6 has the potential to take her gripper socks/shoes off until recently Resident 6 has been completely independent. Resident 6 forgets that she is supposed to be waiting for aides to come and help her. Resident 6 also has days where she thinks that her deceased husband is talking to her. CNA G's statement on [DATE] states, I have seen Resident 6 take off own shoes and gripper socks. Resident 6 has been care planned independent prior to illness. Prior to 1 assist Resident 6 dressed self. CNA H's statement on [DATE] states, This Resident does take off her own clothes. Even though she is a 1 assist. Resident 6 does have good and bad days. On her good days she will/does take her own clothes. Pt does not always use her call light for help. CNA I's statement on [DATE] states, Resident 6 is completely capable of taking her gripper socks off anytime she feels like it. If she feels like she don't want them on she will and will try to get up without putting on the light on. She's supposed to use a walker but she most of the time will not. Important note: staff were aware that Resident 6 took off her gripper socks, could fold up the mat and put it under the bed doesn't use her walker and doesn't wait for assistance. These interventions have been ineffective for fall prevention and have not been reassessed for appropriate to prevent future falls. On [DATE] at 3:55 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding Resident 6's falls. NHA A stated, I don't think the gripper socks being off caused the fall. She (Resident 6) was confused and looking for her husband. NHA Stated, I don't think the gripper socks being on or off would prevent the fall. NHA A gave Surveyor a statement from CNA J that states, Via phone call with NHA A 'Resident 6 did not want to wear her socks to bed on [DATE]. CNA J stated that she attempted to but Resident 6 did not want them on.' NHA A asked CNA J if she put this in her statement and she said no. CNA J stated, 'she would be willing to speak to the survey team.' Surveyor interviewed DON B regarding Resident 6's fall and the gripper socks not on her feet. DON B indicated that the facility is still completing the investigation to the fall and now the facility is aware that Resident 6 can remove her gripper socks. Surveyor asked DON B about the alarm that was not sounding. DON B indicated that the CNA turned the alarm on and questions if Resident 6 turned it off. On [DATE] at 10:09 AM, DON B faxed Surveyor Nursing Assistant documentation for Resident 6 dated [DATE] - [DATE]. This documentation did not mention gripper socks, bed alarms, or 30 minute checks. On [DATE] at 10:09 AM, DON B included a statement regarding Resident 6's falls. DON B's statement included the following: It is found that the CNA's followed the care plan on the day of [DATE]. The bed was in the lowest position, the mat was on the floor next to the bed, and the alarm was in place and turned on by the CNA in bed. It appears the resident may have turned off her alarm. Staff report she has turned off alarms in the past. Of note: there is no documentation that Resident 6 has ever turned off an alarm. Gripper socks were offered. Resident declined the gripper socks, (See statement from CNA J) Staff statements obtained state resident will remove gripper socks and clothing. DON B faxed a statement she wrote that states, The fall did not occur because Resident 6 did not have her gripper socks on. Resident 6 has increasing confusing and weakness due to declining health related to metastatic [DIAGNOSES REDACTED]. The night of her fall she had a toileting need and was looking for her deceased husband. She self- transferred without using call light and was ambulating without her walker. Of note: There is no documentation to show that Resident 6 ever refused the gripper socks except for the statements obtained by NHA A on [DATE] after the survey. The facility failed to implement new fall interventions when Resident 6 was noted to have increased weakness, confusion, and the staff was aware that Resident 6 could remove her gripper socks and turn off her alarm. The facility continued to implement interventions that they knew were ineffective.

Based on observation, interview and record review the facility did not ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident 5) reviewed for falls. Resident 5 fell forward out of her wheelchair on 3/25/16. The facility did not ensure a new intervention was in place to keep her safe. She fell forward out of her wheelchair on 4/4/16 10 days later and fractured her left shoulder. Surveyor observed staff not toilet her after her meal per her care plan for falls and her transfer status was not updated on her care plan. Evidenced by: The facility policy titled Accident Prevention Program/Interdisciplinary (IDT) Fall Prevention Program referenced the AMDA (American Medical Directors Association) Guidelines. The purpose includes in the event of a fall, the IDT Fall Team will evaluate and analyze the root cause of the fall, review the plan of care making revisions as needed and monitor the effectiveness of the interventions as necessary. Under IDT Review of Fall Reports it states to review each fall within 3-5 days and record the review with a summary note in the clinical record. The summary of the Fall Log shall include: the position of the resident prior to the fall; Root cause of the fall; audit of the clinical documentation related to the fall noting whether the note was comprehensive and complete; Audit the plan of care for appropriate interventions making additional revisions as needed to ensure that the root cause is addressed. Ensure that nursing assistant care plan matches the revised plan of care. Example 1 Resident 5 has been a resident at the facility for over 6 years and has [DIAGNOSES REDACTED]. The facility indicated on the initial tour on 4/25/16 that she was not interviewable. Resident 5's Guidelines for daily care dated 4/15/16 state for transfer she requires extensive assist of 2 staff with a gait belt; and take (Resident 5) to her room after meals, toilet her, then lay down in bed. The facility Skin Injury Report dated 3/25/16 states at 9:25 AM Resident 5 incurred a bruise measuring 4 inches by 2 inches to the top of her left forehead. It states for the root cause of the injury Resident (5) fell asleep in her wheelchair and started to lean forward out of her wheelchair. The plan for safety and prevention states, Nursing staff will continue to follow care plan and educate the resident (Resident 5) to ask for assistance when feeling tired or other needs need to be met. The CNA Care Plan updated was indicated not applicable. The report does not state that Resident 5 fell but the statements from staff attached do state that she fell . LPN J's statement states Resident 5 does fall asleep in her wheelchair and leans forward. The facility completed neuro checks for Resident 5. The facility Falls log for March 2016 indicates Resident 5 fell on [DATE], and she fell asleep and leaned forward. Under the new care plan interventions address the root cause of fall it is written care plan appropriate. The IDT Fall meeting for Resident 5's fall on 3/25/16 met on 3/28/16 at 9:43 AM and the result was to continue with the current plan. The facility Post Fall Report for Resident 5 dated 4/4/16 states she fell at 11:25 AM and sustained a skin tear measuring 8.3 cm by 1 cm to her left shin and a skin tear measuring 1 cm by 0.1 cm to her left temple. Later she showed hip pain and received an X-ray that showed a left shoulder fracture. The form indicates Resident 5 is alert but confused and the fall was not witnessed. It states the root cause: Resident (5) is suspected of falling asleep while sitting in her wheelchair resulting in her falling forward. One of the witness statements includes that staff had seen Resident 5 two minutes prior and she was sitting in the day room with her eyes closed and had been sitting with activities. It includes that she likes to lean forward in her wheelchair and has been seen resting her head on tables at times. Another statement states, She gets sleepy easily, which makes it easier for her to fall asleep in chair, and fall out. The IDT Fall meeting for Resident 5's fall on 4/4/16 met on 4/7/16 at 9:00 AM and the result was to get an order for [REDACTED]. On 4/26/16 at 8:40 AM Surveyor observed CNA L push Resident 5 from the dining room to her room to lay her down. CNA M brought the mechanical lift. CNA L and CNA M put the lift sling in place around Resident 5 and transferred her to her bed. CNA L and CNA M asked Resident 5 about her comfort but did not ask or attempt to have her use the toilet. On 4/27/16 at 9:40 AM Surveyor interviewed RN C (Resident Care Coordinator for the unit Resident 5 resides on). RN C stated that she did identify that Resident 5's care plan was not updated to show she should be transferred with a Hoyer (mechanical lift) and was no longer a pivot transfer with 2 staff and a gait belt. RN C stated that the change is usually dated when she updates the care plan and since it was not updated she did not know when Resident 5 was changed from the pivot to Hoyer transfer. RN C explained that after the fall Resident 5 did not want to put her leg down to pivot transfer. On 4/27/16 at approximately 2:00 PM Surveyor interviewed RN C regarding Resident 5's falls. RN C stated that Resident 5 should have been placed on the toilet on 4/26/16 after her meal and per her care plan. RN C stated that her fall on 3/25/16 should have been documented on a Post Fall Report rather than a Skin Injury Report. She agreed that it was not appropriate to educate Resident 5 due to her dementia. RN C assisted Surveyor to clarify with staff working at the time Resident 5 fell on [DATE]. CNA L had been working at the time. Surveyor asked her if RN N (who filled out the Skin Injury Report on 3/25/16) had spoken to her on 3/25/16 after Resident 5's fall. CNA L stated, No. RN C contacted RN N by phone to be interviewed. RN N stated that she was not clear whether the CNAs had followed the care plan so she reiterated Resident 5's current care plan to assist her to toilet and lay down as soon as possible after she is done eating to the CNAs. RN N stated she did not put anything new in place until after Resident 5 fell on [DATE]. Surveyor spoke with LPN H and CNA O who were also present at the time Resident 5 fell on [DATE]. They also did not identify any new interventions that were put in place but that staff had been told to lay Resident 5 down as soon as possible after every meal. RN C stated that she should have reviewed the falls and agreed there should have been something in place to keep Resident 5 from falling forward in her wheelchair.

Based on observation, interview and record review the facility did not ensure sufficient fluid intake to maintain proper hydration and health for 1 of 6 Residents Sampled (Resident 4). Resident 4 admitted to the facility on [DATE] with decreased fluid intake at that time, and then went to the ER (emergency room ) on 4/23/2016 where Resident 4 was provided IV (intravenous) fluids. No evidence the facility monitored Resident 4's daily fluid intake as evidenced by no daily fluid intake totals when she was considered at risk for dehydration. Facility did not recognize that Resident 4's daily fluid needs were not met, thus resulting in the RCC (resident care coordinator), MD (medical doctor/physician), and RD (registered Dietitian) not being notified and no intervention put into place. This is evidenced by: The facility policy, entitled Food and Fluid Monitoring Policy, dated October 2010, states in part: Policy: To assess and monitor residents' food and fluid intake upon admission, upon their quarterly review, upon a change of condition related to nutrition or hydration and as needed for those residents determined to be at risk by the Dietician, Nursing Care Coordinators (also known as Resident Care Coordinator (RCC) )or by the Interdisciplinary Team. Hydration Status Changes -Signs and symptoms of dehydration will be reported to the nurse. The nurse will then complete an assessment and notify the MD as appropriate. -The 24 hour fluid intake totals will be assessed daily by the Night RN Supervisor to ensure that the fluid intake goals are met. If the fluid intake is noted to decrease below the assessed fluid needs (i.e. Less than 1000ml (milliliters) daily average over three days the Night RN supervisor will: Notify the NCC and Dietician to ensure a review of the assessment and plan of care. Notify the Physician/Nurse Practitioner for further discussion related to the plan of care. Notify Social Worker to involve the family/HCPOA (health care power of attorney) as appropriate to discuss options and alternatives. Documentation will be completed by the appropriate discipline. Example 1 Resident 4's emergency department encounter on 04/03/2016 (before admission) states in part: Daughter reports that she is not been eating or drinking much the last several days because she is unable to get around. Resident was admitted to the hospital on [DATE]. Resident 4's Hospital Discharge Summary dated 4/4/2016, at 8:21PM states in part: BASIC METABOLIC PANEL .BUN (Blood Urea Nitrogen) 20 (H) CREATININE 0.69 SODIUM 139 Resident 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 4's Resident Advanced Directives Statement, signed and dated on 4/6/16 states in part: 4. Non Oral feeding (e.g. tube feedings TPN) indicates yes, and 5. I.V for Hydration indicates Yes. Resident 4's Minimum Data Set (MDS) assessment, dated 4/12/2016, indicated that Resident 4's BIMS (Brief interview of Mental Status) is a 14, indicating Resident 4's mental status is not impaired. Resident 4's dietary progress note dated 04/14/2016, at 3:40PM, states: other purpose: (Resident 4) has a very small appetite. She is a small woman. She is eating 25-50% of her NAS (no added salt) diet. Portion sizes adjusted to small portions. She has had some emesis and nursing to monitoring her closely. She has physical deconditioning and is in therapy Resident 4's dietary assessment, dated 04/18/2016, at 5:24PM, states in part: total fluids (mL): 1340 (milliliters). Oral/nutrition intake fluid: LOW RISK: consumes 1,500-2,000mL/day (milliliters per day). Resident 4's Risk level indicated is moderate risk and has had some small emesis of unclear origin. Appetite very small intake very low. Resident 4's dietary progress note dated 4/18/2016, at 5:46PM, states in part: she has caloric needs of 1231 cal/day (calories per day). Fluid needs are 1340 with (½ coming from the food she eats) which leaves 650ml to drink per day. Her fluid intakes (an estimate) are 360-590 (milliliters). Mealtime intake is averaging 25% of breakfast, 25% of lunch and 35-50% of supper. She has habituated to eating a very small quantity daily. These estimates are from the week ending 4-18-16. Progress note also states: she had 3 tissues where she appeared to have spit out some phlegm or small amounts of food items. She has had some emesis of undetermined origin.(Resident 4) is at MODERATE nutritional risk with a score of 6 (3-7=mod) on the nutritional risk assessment. Resident 4's Care plan, printed on 04/26/2016, provided to Surveyor , states in part: Self-care deficit-Interventions include, Eating: I am independent. Initiated on 4/21/16 (Dehydration/Fluid): potential for fluid volume deficit related to: vomiting manifested by: Urinary tract infection Dry mucous membranes. Goal dated 04/21/2016, states three weeks. Interventions include: Monitor Intake/Output Encourage fluid intake include in fluid rounds offer variety of fluids assess mental status changes. Nurse Aide-offer fluids frequently Assist with fluid intake Keep fluids within reach Oral care every shift Vital signs as ordered. CNA (certified nursing assistant) ASSIGNMENT CARD (capitol letters included in text), printed on 04/27/2016, provided to Surveyor , states in part: Eating: I am independent. Offer fluids frequently assist with Fluid intake Keep fluids within reach. Review of Resident 4's dietary records from 4/8/2016 through 4/26/2016 indicated Resident 4 was not meeting her estimated daily fluid needs of 1340mL per day and that her meal intakes remained low as evidenced by documentation of food intake, snack intake and fluid intake. Documentation of Resident 4's meal percentages and fluid amounts provided to Surveyor on 04/27/2016 are as follows: 4/8/2016-Breakfast 100 ML, Lunch 120 ML, Dinner 200ML 4/9/2016-Breakfast 120 ML, Lunch 240 ML,Dinner 180ML 4/10/2016-Breakfast 120ML Lunch 240ML Dinner 380ML 4/11/2016-Breakfast 120ML Lunch 60ML Dinner 60ML 4/12/2016-Breakfast 200ML Lunch 120ML Dinner 240ML 4/13/2016-Breakfast 100ML Lunch 120MLDinner 240ML 4/14/2016-Breakfast 120ML Lunch 0ML Dinner 240ML 4/15/2016-Breakfast 120ML Lunch 0ML Dinner 240ML 4/16/2016-Breakfast 300ML Lunch 50ML Dinner 240ML 4/17/2016-Breakfast 100ML Lunch 200ML Dinner 200ML 4/18/2016-Breakfast 120ML Lunch 120ML Dinner 240ML 4/19/2016-Breakfast 120ML Lunch 200ML Dinner 60ML 4/20/2016-Breakfast 0ML Lunch 120ML Dinner 200 ML 4/21/2016-Breakfast (blank) Lunch 360ML Dinner 200 ML 4/22/2016-Breakfast 460ML Lunch 360ML Dinner 200ML 4/23/2016-Breakfast 120ML Lunch 60ML Dinner 200 ML 4/24/2016-Breakfast 60ML Lunch 100ML Dinner 880ML 4/25/2016- Breakfast 240ML Lunch 240ML Dinner 120ML 4/26/2016-Breakfast 250ML Lunch 150ML Dinner 120ML 4/27/2016-Breakfast 220ML Lunch 100ML Documentation of Resident 4's snacks provided to Surveyor are as follows: 4/8/2016 AM snack 120ML, afternoon snack 60ML, HS (bedtime) Snack 0 ML 4/9/2016 AM snack 0 ML, Afternoon snack 0 ML, HS snack 0 ML 4/10/2016 AM snack 0 ML, Afternoon snack 0 ML, HS snack 100ML 4/11/2016 AM snack 60ML, Afternoon snack 0 ML, HS snack 0 ML 4/12/2016 AM snack 0 ML, Afternoon snack 0 ML, HS snack 120 ML 4/13/2016 AM snack 60ML, Afternoon snack 60ML, HS snack 200ML 4/14/2016 AM snack 0 ML, Afternoon snack 0 ML , HS snack 200ML 4/15/2016 AM snack 0 ML, Afternoon snack 0 ML, HS snack 200ML 4/16/2016 AM snack 50ML, Afternoon snack 50 ML, HS snack 200ML 4/17/2016 AM snack 0 ML, Afternoon snack 0 ML, HS snack 200ML 4/18/2016 AM snack 0 ML, Afternoon snack 0 ML , HS snack 120ML 4/19/2016 AM snack, 0ML, Afternoon snack 0 ML, HS snack 0ML 4/20/2016 AM snack 0ML, Afternoon snack 0ML, HS snack 180 ML 4/21/2016 AM snack 0ML, Afternoon snack 0ML, HS snack 200ML 4/22/2016 AM snack 200 ML, Afternoon snack 100 ML, HS snack 120 ML 4/23/2016 AM snack 0ML, Afternoon snack 0ML, HS snack 25 ML 4/24/2016 AM snack 50ML, Afternoon snack 60ML, HS snack 0 ML 4/25/2016 AM snack 0ML, Afternoon snack 0ML, HS snack 120ML 4/26/2016 AM snack 60ML, Afternoon snack 60ML, HS Snack 120 ML 4/27/2016 AM snack 0 ML, Afternoon snack 0ML Other fluid intake for Resident 4 provided to Surveyor on 04/27/2016 is as follows: 4/23/2016 other PM ML intake 0 4/24/2016 other night ML intake 60 4/24/2016 other AM ML intake 270 4/24/2016 other PM ML intake 880 4/25/2016 other night ML intake 90 4/25/2016 other AM ML intake 120 4/25/2016 Other PM ML intake 60 According to Resident 4's Nutritional assessment dated [DATE], Resident 4's fluid needs had been assessed at 1340ml according to her body weight. Fluid intake documentation provided to Surveyor on 04/27/2016, for Resident 4's April intake reveals: Resident 4's fluid intake was less than her assessed needs for 17 out of 19 days (4/8/16 to 4/26/16). (Please note 24-hour totals calculated by Surveyor based on information provided.) 4/8/2016- fluid grand total in 24 hours = 1200 milliliters 4/9/2016- fluid grand total in 24 hours = 540 milliliters 4/10/2016- fluid grand total in 24 hours = 820 milliliters 4/11/2016- fluid grand total in 24 hours = 300 milliliters 4/12/2016- fluid grand total in 24 hours = 680 milliliters 4/13/2016- fluid grand total in 24 hours = 780 milliliters 4/14/2016- fluid grand total in 24 hours = 560 milliliters 4/15/2016- fluid grand total in 24 hours = 560 milliliters 4/16/2016- fluid grand total in 24 hours = 890 milliliters 4/17/2016- fluid grand total in 24 hours = 700 milliliters 4/18/2016- fluid grand total in 24 hours = 600 milliliters 4/19/2016- fluid grand total in 24 hours = 380 milliliters 4/20/2016- fluid grand total in 24 hours = 500 milliliters 4/21/2016- fluid grand total in 24 hours = 760 milliliters 4/22/2016- fluid grand total in 24 hours = 1440 milliliters 4/23/2016- fluid grand total in 24 hours = 405 milliliters 4/24/2016- fluid grand total in 24 hours = 2360 milliliters 4/25/2016- fluid grand total in 24 hours = 990 milliliters 4/26/2016- fluid grand total in 24 hours = 760 milliliters Resident 4's physician progress notes [REDACTED]. No indication that physician was updated on residents hydration status or fluid intake. Physician/NP (Nurse Practitioner) contact note dated 4/08/2016, at 13:36 (1:36PM) regarding new onset nausea, vomiting, abd (abdomen) tenderness. At 13:56 (1:56PM), regarding previous messages and now resident is running a temp (temperature). Note dated 04/11/2016, at 15:25 (3:25PM) indicating fax sent to physician regarding .at times has had emesis during these times of increased anxiety. 04/20/2016, at 21:18 (9:18PM) Physician/NP contact, attending physician fax sent to (Doctors name) in regards to 3.6 pound weight loss in 1 week 04/22/2016 11:18 (11:18AM) result: new orders received and noted 04/22/2016 for protein supplement and at 14:39 (2:39PM) stating fax received from attending physician (Doctors name) low blood pressures and continued nausea new orders received and noted 04/22/2016 to d/c (discontinue) [MEDICATION NAME] (blood pressure medication) and start [MEDICATION NAME] (anti-nausea medication) prn (per request needed) for nausea. Of note the documentation does not indicate any information regarding consulting with the physician about her low fluid intake. Resident 4's Nurses notes are as follows: 04/05/2016, at 12:11PM states in part: HYDRATION FINDINGS: no problems noted Skin turgor WNLs (within normal limits). Mucous membrane moist . IV INPUT: No fluid input by IV or tube in the last 7days .ACTION: Continue to observe will offer fluids with cares and interactions. (Please note Resident 4 received IV fluids in the hospital prior to admission to facility on 4/5/2016) 04/07/2015, at 19:05 (7:05PM) states in part: WEEKLY SKIN ASSESSMENT: GENERAL SKIN CONDITION: no problems noted skin intact within normal limits DESCRIPTION: pale, warm, dry . 04/08/2016, at 13:39 (1:39PM), Nurses note states in part: vomiting, small emesis on day shift early afternoon COMMENTS/NOTES: Resident has a fever of 101.0 noted around 13:15 (1:15PM), Tylenol 1000mg given. 4/08/2016, at 22:03 (10:03PM), Nurses note states in part: MUCOUS MEMBRANES: moist 04/09/2016, at 21:03 (9:03PM), Nurses note states in part: MUCOUS MEMBRANES: moist 04/11/2016, at 03:59 (3:59AM), Nurses note states in part: Late entry for: 04/10/2016 Time: 15:45 (3:45PM) .administered: Push fluids of her choice and fresh water at bedside every shift. Minimum of 4oz. (ounces) every hour W/A (while awake) PROCEDURE RESULTS: unchanged r/t (related to) resident not wanting fluids as much as staff has offered. BP continues to be labile and hypotensive (low blood pressure) and asymptomatic. Resident does not appear to be dehydrated: skin turgor < 3 (less than 3) seconds, oral mucous is moist, tongue is not dry and cracked, and urination is comparable to oral intake, currently. 04/11/2016, at 14:33 (2:33PM), Nurses note states in part: VOMITUS: small amount ACTION: Continue to observe 04/12/2016, at 02:10 (2:10AM), Nurses note states in part: MUSCOUS MEMBRANES: moist .ACTION: Continue to observe changes in GI (gastrointestinal) status. 04/12/2016, at 09:57 (9:57AM), Nurses note states in part NUTRITION: Probably inadequate - Rarely eats full meal, usually eats ½ (half) food offered. Eats 3 protein/day. Occ. (occasional) supplement. 04/12/2016, at 22:49 (10:49PM), Nurses note states in part: MUCOUS MEMBRANES: moist 04/13/2016, at 01:38 (1:38AM), .MUCOUS MEMBRANES: moist 04/13/2016, at 13:03 (1:03PM), VOMITUS: moderate amount, Resident reported feeling queasy while on elevator. When she got to the floor she began to vomit . 04/14/2016, at 11:24 (11:24AM), Resident had a small emesis around 11am 04/15/2016, at 23:05 (11:05PM),DIGESTIVE FINDINGS: vomiting, amount of undigested food, denied nausea before .VOMITUS: large amount, yellow, with undigested food MUCOUS MEMBRANES: moist ACTION: Continue to observe COMMENTS/NOTES: VS after emesis BP (blood pressure) 84/52 04/16/2016, at 15:11 (3:11PM), VOMITUS: small amount 04/17/2016, at 13:33 (1:33PM), DIGESTIVE FINDINGS: emesis on AM shift .VOMITUS: Orange thin substance MUCOUS MEMBRANES: moist 04/20/2016, at 21:28 (9:21PM), PHYSICIAN/NP CONTACT: attending physician fax sent to (Physicians name) in regards to 3.6 pound weight loss in 1 week 04/22/2016, at 10:33 (10:33AM), CIRCULATORY FINDINGS: low B/P 72/42 experiencing fatigue denies any dizziness or lightheadedness .COMMENTS/NOTES: meal and fluid intake is poor, will encourage fluids. (Physicians name) was faxed regarding these low blood pressures 04/22/2016, at 14:39 (2:39PM), PHYSICIAN/NP CONTACT: fax received from attending physician (physician's name) REGARDING: low blood pressures and continues nausea 04/23/2016, at 00:59 (12:59AM), Nurses note states in part: 04/23/2016, at 14:03 (2:03PM), PHYSICIAN/NP CONTACT: spoke with (physician name) to report resident with temp 101.8, HR 104, SPO2 87-90% RA (oxygen saturation 87-90% room air). Emesis yesterday. DNR. Requesting order for CXR (chest x-ray), prn oxygen and nebs. (Physician name) wants her (Resident 4) seen in the ER. Writer again states we can do CXR, labs and treat here he (physician) states no, he does not want to treat over the phone. Writer will talk to resident and arrange for transport to ER. 04/23/2016, at 14:04 (2:04PM), BLOOD PRESSURE: 103/67 PULSE: 104 TEMPERATURE: 101.3 ¿ (ax) (axillary) RESPIRATORY RATE: 20 O2SATURATION: 88% on room air 04/23/2016, at 14:18 (2:18PM), Call to EMS, non-emergent transport at 1415 (2:15PM) . 04/23/2016, at 18:42 (6:42PM) Time: 18:20 (6:20PM) PHYSICIAN/NP CONTACT: spoke with (name of RN at hospital) at (hospital name) ER. Will be sending (Resident 4) back. UTI (urinary tract infection) and CXR both negative. IV fluids given for dehydration and [MEDICAL CONDITION] infection. 04/23/2016, at 21:45 (9:45PM), ACTION: Physician notified orders received continue to observe COMMENTS/NOTES: resident returned via (town name) cab to (nursing home), without family or friend, at 1910 (7:10PM). Charge nurse updated 04/23/2016, at 21:51 (9:51PM, HYDRATION FINDINGS: poor skin turgor/tenting, mucous membranes moist; encouraging fluids of her choice W/A COMMENTS/NOTES: Noted bruising from labs, and IV, from ER Dept. (department) ACTION: Continue to observe Encourage to rest Repositioned 04/24/2016, at 12:01 (12:01PM), HYDRATION FINDINGS: poor skin turgor/tenting ACTION: Continue to observe COMMENT/NOTES: fluids encouraged 04/24/2016, at 17:55 (5:55PM), HYDRATION FINDINGS: no problems noted 04/25/2016, at 02:14 (2:14AM), HYDRATION FINDINGS: dry mouth, oral fluids encouraged. IV THERAPY: none TEACHING DONE: hydration orally ACTION: Continue to observe for changes in residents sensorium and skin and mucus membrane changes. 04/25/2016, at 11:26 (11:26AM), HYDRATION FINDINGS: poor skin turgor/tenting fluids encouraged ACTION: Continue to observe 04/25/2016, at 23:05 (11:05PM), HYDRATION FINDINGS: no problems noted PROCEDURE DONE: fluids encouraged ACTION: Continue to observe 04/26/2016, at 02:12 (2:12AM), HYDRATION FINDINGS: dry mouth IV INPUT: none ACTION: Continue to observe for signs of dehydration. Will encourage fluids when awake during rounding and position changes. 04/26/2016, at 09:22 (9:22AM), HYDRATION FINDINGS: dry mouth IV INPUT: none ACTION: Continue to observe 04/26/2016, at 23:25 (11:25PM), HYDRATION FINDINGS: no problems noted PROCEDURE DONE: fluids encouraged TEACHING DONE: Resident/family aware of [DIAGNOSES REDACTED]. Upon record review Surveyor , noted a telephone order dated 4/23/2016, indicating send to ER for evaluation and treatment due to fever, crackles, decreased oxygen saturation and increased lethargy. Resident 4 was sent to the ER (emergency room ) on 4/23/2016. ED (Emergency Department/emergency room ) provider note time: 4/25/2016 2:13PM, indicates chief complaint was fever. HPI (history of present illness) comments states: this nursing home resident reportedly vomited on the previous day and was reportedly lethargic and having difficulty answering questions while at the nursing home today. Physical exam states in part: ED triage vitals on 04/23/2016, at 1453 (2:53PM)Temp (temperature) 100.1¿F (degrees Fahrenheit) tympanic, pulse 85, Resp (respirations) 14 BP (blood pressure) 104/57. HEENT (Head, ears, eyes, nose and throat) states in part: Pharynx and mouth mildly dry. ED course states in part: patients physical and laboratory findings consistent with mild dehydration and sodium chloride infusion 0.9% (Intravenous Stopped 4/23/16 1816 (6:16PM)). COMPREHENSIVE METABOLIC PANEL (CPANEL) -Abnormal; notable for the following: .BUN 37 SODIUM 131 .POTASSIUM 5.5 Resident 4's Discharge to Nursing Home, dated 04/23/2016, states in part: Resume standing orders New orders: 1)[MEDICATION NAME] (Tylenol) 1g every 6 hours as needed for fever 2) plenty of fluid to drink Fax sent to Resident 4's physician on 4/25/2016, at 8:43AM, states in part: .Resident sent to ER at 1430 (2:30PM) per order from the on-call (physician name). She had temp (temperature) of 101.8 POX (pulse oxygenation) 87-90% RA .At 1900 (7:00PM) resident returned to (nursing home) Dx (diagnosis) dehydration and [MEDICAL CONDITION] illness . Subsequent to Resident 4's return to the nursing home, the facility did not update her care plan with respect to monitoring or increasing fluid intake. Even though she was dehydrated when evaluated and treated at theER on [DATE]. No interventions were added upon her return to ensure adequate hydration. On 04/27/2016, at 8:45AM, Surveyor , Interviewed RN F related to monitoring hydration status. RN F indicated RD G reviews nutritional status when MDS assessment is due. RN F indicated she looks at hydration status when it's brought to her attention. RN F indicated she gets message in (computer system) related to weights, vitals, discharges, skin issues and falls. RN F indicated she checks for her own residents then does a weight review by reviewing weights since admit, if 5 pounds in a week, then start review process if weekly weight then reweigh and if weight still the same would check food intake and find a reason for weight loss. On 04/27/2016, at 3:10PM, Surveyor , Interviewed Resident 4 related to fluids. Surveyor asked if anyone offers her fluids, Resident 4 stated: I don't think so. Surveyor asked Resident 4 again, Resident 4 then stated, I don't remember. Surveyor asked Resident 4 if staff offers her fluids throughout the day, Resident 4 stated, I guess not. Surveyor observed there was no water pitcher/cup in resident's room at this time. On 4/27/2016, at 3:25PM, Surveyor , Observed there was no water pitcher/cup in room, Resident 4's bedside table was near other bed closer to Resident 4's room door, and Resident 4's wheel chair was near the bed and facing the bed. Resident 4 indicated she was dry, Resident 4's lips appeared dry, and Surveyor , observed Resident 4 trying to lick her lips. Resident 4's NUTRITION care plan was changed on 04/27/2016 21:05 (9:05PM), care plan states: PROBLEM (NUTRITION): Marginal food and fluid intake RELATED TO: Decreased appetite Pain Nausea with emesis arthritis, DJD, Compression Fracture, Physical deconditioning, habituation to limited food/fluid intake. MANIFESTED BY: Leaves > 25% food uneaten Muscle wasting, low weight and small size, inadequate intake for one week, most meals 25% for the past 3 days. GOAL: will Eat: Drink: 25-50% GOAL TIME: two weeks. Nurses-Identify influencing factors (eg: depression, anxiety, dry mouth, functional deficits, pain, behaviors) Plus 2 milk shakes added 60 ml QID (four times a day) med pass. Nurse Aide-Set up foods as needed Provide cues and encouragement offer fluids frequently. Dietary-Determine food likes/dislikes Dietary consult by RDN, small portions added to meal plan. SocServ-Identify mood indicators Activity-Provide snacks during activities. Offer fluids at activities All calories are BENEFICIAL EVALUATION: goal was not met for eating 50%, updated care plan goal. 04/27/2016 (no time) DIETARY PROGRESS NOTE states in part: Review of (Resident 4's) intake for the past week ending 4-27-2016. She was out of the building on 4-23-2016 for part of the day. See RN notes from ER visit and IV fluids. Her very limited intake continues of 0-100% with most meals at 25%. Fluids of all varieties encouraged. The past 3 days she has eaten 25% at Breakfast, 0- 25% at lunch, and 25% for supper. She was started on Plus 2 60ml QID on 4-22-2016. Whatever she drinks of these shakes will benefit her as they are a high quality protein and 2 calories per ml. She weighed 114.6# (pounds) on 4-23-16. This is at the bottom of her range 114-125.6# since admission here. She was 124-128# in the hospital prior to admission. See skin assessment by RN 4-24-16 and new skin area 4-27-16. She refused her vitamins on 4-24-16. Oral fluid intake varies widely. Mealtime intake is usually 120-240 ml/meal. Encouragement given for all caloric dense food items. ASSESSMENT TYPE: Significant Change .WEIGHT (lbs.): 115lbs .CALORIE NEEDS: 1136 TOTAL FLUIDS(mL): 2648 WEIGHT STATUS, LOSS OR GAIN: LOW RISK: BMI 19-27 BMI=20 Now 114-118# ORAL/NUTRITION INTAKE,FOOD:MODERATE RISK: Intake meets 26-75% of estimated needs ORAL/NUTRITION INTAKE, FLUID: MODERATE RISK: Consumes 1,000-1,499mL/day some days HIGH RISK: Consumes , 1,000mL/day fluids are encouraged Plus 2, mealtime intake, 4 oz frequently TOTAL SCORE: 14 RISK LEVEL: high risk COMMENTS: Marginal intake continues with new [MEDICAL CONDITION] illness, skin issues, and IV Fluids inER on [DATE] DIETARY PROGRESS NOTE: Other purpose: Recalculated Nutritional Risk. Now at HIGH nutritional risk with a score of 14 (>8=high) with more than a week of very limited food and fluid intake. See dietary notes and nutritional risk assessment. On 04/28/2016, at 7:15AM, Surveyor interviewed LPN (Licensed Practical Nurse) H related to hydration status and fluid needs. LPN H indicated that poor skin turgor and dry mucous membranes means they're dehydrated. LPN H indicated CNA charting for what a resident drinks or eats for the day, and CNA charting for output for Foley, amount or times go to the bathroom or incontinent, when asked how you would know if a resident is, meeting daily fluid needs. LPN H indicated she did not know who totals up the daily fluid intake. LPN H indicated she did not know where to find the daily estimated fluid needs. On 04/28/2016, at 7:30AM, Surveyor interviewed RN I, related to hydration status and fluid needs. RN I indicated would go through and total up I/O per shift when monitoring I/O . RN I indicated she did not know who does the fluid totals. RN I also indicated she did not know where estimated fluid needs are located and that a resident is meeting their daily fluid needs if skin turgor is good and amount of fluid in equals the amount of fluid out. RN I came back to Surveyor , at 8:00AM, indicated night shift totals up fluid intakes, and that RD G in dietary calculates the estimated daily fluid needs. On 04/28/2016, at 7:47AM, Surveyor interviewed LPN J, related to hydration status and fluid needs. LPN J indicated CNA's put intake into the computer, someone goes back in, looks at it, and totals it, and that fluid intakes are totaled per shift. LPN J indicated does not know where estimated fluid needs are found. On 04/28/2016, at 7:57AM, Surveyor interviewed RN K, related to hydration status and fluid needs. RN K indicated color, skin health and weights indicate if a resident is receiving daily fluid needs. RN K indicated she did not know where to find estimated fluid needs. RN K indicated that the computer totals up intakes unless on strict I/O. On 04/28/2016, at 8:35AM, Surveyor , interviewed RD (Registered Dietician) G, related to residents being at risk for dehydration. RD G indicated she looks at how much fluid they are getting in food and fluid intake. Surveyor asked RD G about Resident 4's daily fluid needs, RD G indicated 1340ml (milliliters) is a minimum need for the day, more fluid would be better, of the 1340ml she is looking to see how much is coming from food as well as fluids for Resident 4. RD G stated she's Marginal and indicated Resident 4 is right on the line, when asked if Resident 4 is getting half her fluid needs from food based on what Resident 4 eats. Surveyor , asked RD G, how she assures that Resident 4 meets half her fluids needs from food, RD G indicated she could only go by clinical knowledge and assessment. Surveyor asked RD G if Resident 4 was meeting her needs, RD G stated No and indicated Resident 4 was 10% below marginal needs. Surveyor asked RD G if water from food supplements oral fluid intake, RD G stated yes, Surveyor , asked RD G what SOP (Standard of Practice) that is from, RD G indicated she would find the SOP. RD G indicated she was notified Resident 4 had gone to the hospital and returned on 4/23/2016. RD G indicated to Surveyor , she was not sure the exact date or time she was notified regarding Resident 4. RD G stated yes indicating she reassessed Resident 4, RD G stated Yesterday, indicating she reassessed Resident 4 on 04/27/2016. RD G indicated that Resident 4's 04/18/2016, ORAL/NUTRITION INTAKE, FLUID: LOW RISK: Consumes 1,500-2,000mL/day was not accurate, that she just clicks a button and did not calculate it, the computer does it after inputting height, weight, usual body weight range, activity factor, injury factor, protein factor, fluid, factor, BMI (body mass index) etc RD G indicated she does not know nursing protocol when asked who totals the fluid intakes. Surveyor asked RD G what Marginal meant, RD G stated, Marginal meant at minimum requirement and it puts her (Resident 4) at risk. On 04/28/2016, at 9:08AM, Surveyor interviewed RD G related to nutritional needs. RD G indicated that she saw Resident 4 had a stage 2 pressure injury in Resident 4's chart on 4/27/2016. RD G stated No indicating Resident 4 is not meeting fluid needs and that Resident 4's fluid needs have gone up significantly. On 04/28/2016, at 10:07AM, Surveyor interviewed RD G related to Resident 4's ER visit. RD G indicated she briefly read it (ER note), that they ruled out pneumonia and urinary tract infections, and that they gave fluids for a [MEDICAL CONDITION] infection and dehydration. RD G indicated she looks at the H&P (History and Physical) as part of the total clinical assessment to do a better job in taking care of her. Surveyor , asked RD G to clarify what she meant by not accurate in earlier interview related to computer calculation. RD G indicated she does not like the word accurate, and that a click button comes up automatically, the total needs are calculated automatically, and that is a mathematical guideline put with clinical assessment. RD G stated yes indicating the calculation is a guideline, and would not use the calculation if she didn't feel it was helpful. On 04/28/2016, at 10:20AM, Surveyor , interviewed RN F related what she would do related to poor skin turgor/dry membranes and suspected dehydration. RN F indicated to check food and fluid, ask staff to push fluids and encourage as much intake as we can. Upon return from ER, residents would be put on 3 day assessment related to diagnosis. If [DIAGNOSES REDACTED]. When asked what monitor I/O means RN F indicated that when its put into the computer aids (certified nursing assistants) have extra charting and the NOC (night) supervisor calculates the total. When Surveyor , asked how staff finds out a resident is on I/O, RN F indicated any new admit is on I/O for 3 days, if they go to the ER with [DIAGNOSES REDACTED]. RN F indicated to figure out if residents are meeting their daily fluid needs, she would look at CNA (Certified Nursing Assistant) charting for intake, meals, and snacks. RN F indicated to Surveyor , that the estimated daily fluid needs are found in the nutrition assessment. RN F also indicated to Surveyor , that once night shift totals daily fluid intake it's written down in 24 hour book and that the 24 hour book is looked at each shift. Surveyor asked RN F if Resident 4's Physician should have been notified regarding decreased fluid intake, RN F stated Yes. RN F indicated to Surveyor , that Resident 4 was on strict I/O for 3 days upon admission on 4/5/2016, which meant the CNAs has increased charting. RN F stated, yes when Surveyor , asked if Resident 4 was placed on strict I/O on 4/23/2016 and indicated strict I/O meant intake only. RN F stated No indicating she was not alerted that Resident 4 was not meeting daily fluid needs from 4/8/2016 to present. On 04/28/2016, RN F provided Surveyor , with a copy of IDT note, dated 04/22/2016, at 14:15 (2:15PM) which states in part: SOCIAL SERVICES NOTE: .She is having difficulty with eating meat sandwiches and dietary to be notified. Please note no evidence was provided that Resident 4's fluid intake had been discussed on 04/22/2016. On 04/28/2016, at 1:00PM Surveyor , and Surveyor , spoke with NHA (Nursing Home Administ

Based on interview and record review, the facility did not immediately consult with the resident's physician when there was a significant change in the resident's physical status and a need to alter treatment significantly for 1 of 3 residents reviewed for significant changes (Resident 4). Resident 4 was noted to have swelling and redness to the jawline, as well as increased temperatures. Resident 4's physician was not immediately consulted. When Resident 4's physician was consulted several hours later, an order was prescribed for [MEDICATION NAME]. The facility did not have evidence that this medication was provided to Resident 4. The facility did not recognize Resident 4's change in condition and Resident 4 was sent to an acute care facility after the family of Resident 4 insisted. Resident 4 was diagnosed with [REDACTED]. This is evidenced by the following: Ludwig's [MEDICAL CONDITION] is defined by the American Academy of Emergency Medicine, Evidence-Based [DIAGNOSES REDACTED].<javascript:newshowcontent('active','authordisclosures');>February 15, 2007, is characterized as a rapidly progressive gangrenous [MEDICAL CONDITION] of the soft tissues of the neck and floor of the mouth.(52) <javascript:newshowcontent('active','references');> With progressive swelling of the soft tissues and elevation and posterior displacement of the tongue, the most life-threatening complication of Ludwig's [MEDICAL CONDITION] is airway obstruction...In Ludwig's [MEDICAL CONDITION], the submandibular space is the primary site of infection.(54) <javascript:newshowcontent('active','references');> ...Once infection develops, it spreads contiguously to the sublingual space. Infection can also spread contiguously to involve the pharyngomaxillary and retropharyngeal spaces, thereby encircling the airway." The facility's policy titled, "Change of Condition (Acute)" dated 7/2012 states, "Policy: A resident experiencing an acute change in condition (ACOC) will receive prompt recognition, assessment, interventions and monitoring. ACOC in resident's medical/mental condition will be recognized and notification will be provided to the resident, HCPOA, MD or provider of acute change of condition. Purpose: The purpose of the policy is to identify acute change of condition in a timely manner, enabling staff to evaluate and either manage the residents care at the facility and decrease transfers to the hospital/emergency room or send the resident for needed care to acute care setting. Definition: An acute change of condition (ACOC) is a sudden, clinically important deviation from a resident's baseline in physical, medical, cognitive, behavioral, or functional areas. "Clinically important" means a deviation that, without intervention, may result in complications or death ..." Director of Nursing (DON) B indicated that the facility follows Interact II tools as their standard for changes in condition. This document states the following: "CARE PATH: Fever; Fever definition:? One Temp > 100?F (>37.8?C); > 2 Temps > 99?F (>37.2?C) oral, or > 99.5?F (>37.5?C) rectal; Increase in Temp of 2?F (1.1?C) over baseline; Take Vital Signs: ? BP, Pulse, Respirations, Oxygen saturation, Finger stick glucose (diabetics). Vital Sign Criteria (any met): ? Temp > 102?F (> 38.9?C), Apical heart rate > 130 or < 50?; Respiratory rate > 28/min or < 10/min?; BP < 90 or > 210 systolic?; Oxygen saturation < 90%?; Finger stick glucose < 70 or >400?; Yes? Notify MD/PA/NP immediately. No? Further nursing assessment: Mental Status, Functional Status, Respiratory, Gastrointestinal, [MEDICAL CONDITION], Skin. Evaluate Symptoms and Signs: Acute mental status change? Not eating or drinking? Acute decline in ADL abilities? New cough, abnormal lung sounds? Nausea, vomiting, diarrhea, abdominal distention or tenderness? New or worsened incontinence, pain with urination, blood in urine? Very low urinary output? New skin condition, e.g., rash, redness suggesting cellulitus, signs of infection around existing pressure ulcer? Yes? Notify MD/PA/NP immediately. No? Manage in Facility-Options: Monitor vital signs and urine output every 4-8 hours for 24-72 hours. Consider a complete blood count. Do Not give [MEDICATION NAME] unless necessary for comfort (it can mask a worsening fever) or until source of fever known. Take Vital Signs: BP, Pulse, Respirations, Oxygen saturation, Finger stick glucose (diabetics); Consider: Lab tests as indicated, Transfer to acute care facility as indicated. Evaluate Symptoms and Signs: Acute mental status change? Not eating or drinking? Acute decline in ADL abilities? New cough, abnormal lung sounds? Nausea, vomiting, diarrhea, abdominal distention or tenderness? New or worsened incontinence, pain with urination, blood in urine? Very low urinary output? New skin condition, e.g., rash, redness suggesting [MEDICAL CONDITION], signs of infection around existing pressure ulcer? NOTIFY MD/NP/PA if any criteria for transfer met." The American Medical Directors Association, Acute Changes of Condition in the Long-Term Care Settings, Copyright 2004 indicates to report the following symptoms immediately to the practitioner: -Vital signs-Oral temperature of over 101 degrees Fahrenheit, Complaint- medical by family or patient, Sore throat-accompanied by respiratory distress or painful swallowing. According to "Diseases Index Report", Resident 4 has [DIAGNOSES REDACTED]. The facility completed a quarterly Minimum Data Set (MDS) assessment with a target date of 2/11/14. This assessment notes that Resident 4 scored 12 points on her Brief Interview for Mental Status, indicating moderate cognitive impairment. The facility completed "Weight and Vitals Flow Sheet" for Resident 4. Entries for temperature are as follows: 1/22/14: 97.7 1/29/14: 98.0 2/19/14: 98.3 3/5/14: 97.6 3/19/14: 102.4, 99.5 3/20/14: 97.2, 98.6 3/21/14: 99.1 at 8:00 PM 3/22/14: 100.2 at 1:30 AM, 101.2 at 4:00 AM, 100.4 at 5:15 AM, 100.4 at 7:20 AM Resident 4's "Nurses' Notes" dated 3/19/14 state, "0810 (8:10 AM). Resident presents c (with) fever. T (temperature)= 102.4, P (pulse) 118, R (respirations) 20, BP (blood pressure) 140/85. She is alert, slower to respond than usual, eyes appear gloss/sick. Skin is hot & flushed. No swollen lymph nodes palpated on neck. Shakes head 'no' when asked if her throat was sore. Clear drainage dripping from her nose. No cough. LS (lung sounds) clear. BS (bowel sounds) X 4, abd (abdomen) soft, non-tender and round. Left LE (lower extremity) and hand c slight [MEDICAL CONDITION] per usual. (affected side from [MEDICAL CONDITION]). Shakes head "no" when asked if having painful urination or difficulties urinating. Blood sugar this AM=160 which is higher than usual for this resident. Call placed to the office of (Nurse Practitioner) and Dr ...0945 ...New order received for UA (urinalysis) C&S (culture and sensitivity) due to fever, decline in functional status) ...." Resident 4's "Nurses' Notes" dated 3/20/14 state, "0215 (2:15 AM) Resting quietly, skin warm and dry. No pain. Takes PO (by mouth) fluids when offered. 1400 (2:00 PM) Alert. Skin warm and dry. Denies pain. Ate 50% lunch and went to Club 48 for a special lunch. No c/o (complaints of) burning or pain with urination. Voided X2 this shift ..." Resident 4 was seen on 3/21/14 by Nurse Practitioner (NP) E. NP E document the following: "Chief Complaint: UTI; History of Present Illness: This is a [AGE] year-old women ...who had reports on March 19 had a low-grade fever, was not wanting to eat or drink participate in activities. Not acting like herself. Nursing assessment was done. She had no cough, signs or symptoms of urinary tract infection. No diarrhea. No nausea. No vomiting. I did order a straight cath UA at that time, and asked that she be monitored closely. By the next day she was back to participating in activities and her oral intake had improved, and overall she was doing better ...Today, (Resident 4) has no complaints. She was eating a hamburger in her room when I saw her. She answered questions slowly but appropriately. She denied fever, chills. Occasional cough, but non-productive. No shortness of breath. No abdominal pain ..." "Nurses' Notes" dated 3/21/14 state, "1500 (3:00 PM) ...New order received-started on Doxycylcline 100 mg (milligrams) BID (twice per day) X (for) 10 days ...2230 (10:30 PM) Abx (antibiotic) started. Redness and warmth and swelling along the left jaw line & below chin. Temp 99.1. Scheduled Tylenol given. Took pills but did not swallow all of them & refused to open mouth of drink more water. Cool compress applied to jaw line ...(Signed by RN (Registered Nurse) C)." (Please note that the facility interact care path for fever states to not give Tylenol unless for comfort as it may mask the fever until the origin of the fever is found.) The facility did not consult with a physician regarding Resident 4's new symptoms of a reddened and swollen jaw, refusal to open mouth and not swallowing her medications. "Nurses' Notes" dated 3/22/14 at 2:30 AM state, "Cont (continues) c redness swelling and warmth across left jaw line to Rt (right) jaw. Cold compress applied. Refused oral fluids when offered. Voided large amount of urine. No blood." It is important to note the 3/22/14 recorded temperatures above of 100.2 at 1:30 AM and 101.2 at 4:00 AM. The facility did not consult with a physician regarding Resident 4's continued redness and swelling of the jaw, refusal of oral fluids and increased temperature. "Nurses' Notes" dated 3/22/14 at 8:30 AM, written by RN D, state, "floor nurse reports resident has redness & swelling to jawline & chin. Upon assessment (Resident 4) has redness, warmth, firmness & swelling noted to jawline and under chin. C/O discomfort c palpation & c/o "throat sore." (Resident 4) says it seems harder to swallow. No respiratory distress noted. Respirations even & non-labored. Able to take AM medications. Resident was started on [MEDICATION NAME] for UTI (urinary tract infection) on 3/21/14. On call (MD) updated via phone call. New orders received." A "Physician's Telephone Orders" dated 3/22/14 states, "D/C (discontinue) [MEDICATION NAME]. Abx pending culture. [MEDICATION NAME] 25 mg PO q (every) 6 hours PRN (as needed)." Resident 4's Medication Administration Record [REDACTED]" was hand written onto the MAR indicated [REDACTED]. "Nurses' Notes" dated 3/22/14 at 9:00 AM state, "Phone call received from MCH lab. Resident [MEDICAL CONDITION] + (positive) urine. Placed on contact isolation. C&S received via fax r/t (related to) UA. Dr. (name) updated via phone call re:[MEDICAL CONDITION] + urine & C&S. No new orders." "Nurses' Notes" dated 3/22/14 at 1:00 PM state, "Resident resting in bed at this time. Refused lunch. Skin warm and dry. Redness and swallowing (SIC) remains to the jaw area." "Nurses' Notes" dated 3/22/14 at 2:15 PM state, "Family requesting their mother be sent over for eval of redness. Resident alert and making eye contact. Nods yes or no to some questions. Pox (oxygen saturation) 93% on RA (room air). P 70. Lungs clear. No respiratory distress. C/O of sore throat. Redness continues to neck along with swelling. Swelling more prominent on right jaw than left jaw. Redness firm on under side of chin. Daughter ...and sons requested transport." "Nurses' Notes" dated 3/22/14 at 2:40 PM state, "Call received from floor nurse re: family wanting resident sent to ER. Spoke c family re: (MD) updated and new orders. Explained to family that (Resident 4) c/o throat "being sore" but has no signs of respiratory distress. (Resident 4) awake and alert c non-labored respirations during conversations c family. Family members again request ER evaluation. Family told that (Nurse Practitioner) will be here on Monday & can see (Resident 4) to address her current health issues since resident is not in any distress (respiratory or pain wise) & family stated that "Monday is a little too long to wait don't you think." ...Family informed that on call Dr. (name) would be updated. Phone call placed to on-call Dr. (name) new order received for ER evaluation per family request ...Monroe cab called per floor nurse, family also updated [MEDICAL CONDITION]+ urine. 1500 (3:00 PM) Resident transported via Monroe Cab from PVNH to MCH ER per family request ...1930 (7:30 PM) Family came to facility to report that resident will be transferred to UW Hospital to be admitted for treatment ..." A "Physician's Telephone Orders" dated 3/22/14 states "Send to ER per family request." "Discharge Summary" dated 4/21/14 from Select Specialty Hospital states, "Discharge Diagnosis: [REDACTED]. History of [MEDICAL CONDITION] embolism and [MEDICAL CONDITION] 3. Steroid-induced [MEDICAL CONDITION] 4. History of [MEDICAL CONDITION] with cerebral metastases 5. Dysphagia 6. Hypertension 7. History of [MEDICAL CONDITION] with residual left-sided weakness ...Hospital Course: The patient is a [AGE] year-old female with a history of chronic steroid use, history of [MEDICAL CONDITION] with brain metastases, status [REDACTED]. She is also status [REDACTED]. She presented to the University Hospital and Clinics with four days of jaw pain, redness, difficulty swallowing and swelling. CT scan revealed a possible early Ludwig [MEDICAL CONDITION]. She is started initially on intravenous [MEDICATION NAME] beginning on 3/20/2014 (SIC - the resident was not hospitalized until 3/22/14). After CT scan results were reviewed, her antibiotic therapy was broadened to [MEDICATION NAME] and [MEDICATION NAME] on 3/23/14. She underwent an incision and drainage of submental abscess by underwent otolaryngology on 3/23/14. Cultures from the time were negative. Antibiotics were eventually narrowed to [MEDICATION NAME]/sulbactam. She was successfully extubated on 3/25/14 and remained hemodynamically stable. She underwent a swallow evaluation and was deemed not safe for oral intake. She was started on Dobbhoff tube feeds..." The facility conducted an investigation into the matter after Resident 4's family member brought the concern of "that if they didn't come and visit that she wouldn't have been sent," according to a statement written by Social Worker (SW) G. Included in the facility's investigation is a statement as follows: "After this chart review, it appears Pleasant View staff performed appropriate notification to medical providers with changes in condition. Orders were followed. Family was updated as needed as (Resident 4's) HCPOA (Health Care Power of Attorney) document is not activated; she is not incapacitated." This statement is signed by RN F. Surveyor spoke with RN C on 5/15/14 at 3:10 PM. RN C stated that she worked PM shift on 3/21/14. Surveyor asked RN C when she would call the physician regarding a resident's high temperature. RN C stated that she would call the physician if a resident's temperature reached 100 or 100.1 degrees. Surveyor asked RN C about Resident 4's condition on 3/21/14. RN C stated that she called her supervisor and was instructed to place a cold compress on (Resident 4's) jaw as she had a UTI at the time as well and that it was thought to be from a tooth abscess. RN C stated that she was not sure if this was effective as it was the end of her shift around 10:00 PM. (Please note that if it was thought to be a tooth abscess, with symptoms of pain, difficulty swallowing, refusing to take fluids and eat food, this is a change of condition and should have been called to the MD immediately.) Surveyor spoke with RN D on 5/15/14 at 3:15 PM. RN D stated that she was the weekend supervisor during the time of (Resident 4's) swelling and redness to the jaw. Surveyor asked RN D when she would call the physician related to temperature and change in condition. RN D stated that if a resident's temperature reached 101 to 102 degrees, a call would be made. Surveyor asked if she would expect staff to call a physician with a fever as well as redness and swelling to the jaw. RN D stated that she would have expected a call out around the 1:30 AM time of (Resident 4's) change. RN D stated that she received the order for the [MEDICATION NAME] and that this was prescribed as it was viewed as a possible allergic reaction. RN D stated that the floor nurse would be expected to give the dose. RN D stated that she would have expected a dose of [MEDICATION NAME] be given to (Resident 4) when it was ordered. RN D stated the (Licensed Practical Nurse (LPN) H) should have given the [MEDICATION NAME]. Surveyor spoke with DON B on 5/15/14 at 3:25 PM. DON B stated that notification of temperature to the physician depends on the resident's baseline. DON B stated that she expects staff to recheck temperatures if they are out of the ordinary. DON B stated that she would have expected a call to a physician (for Resident 4) at 1:30 AM, during the night shift. DON B stated that she would expect that the [MEDICATION NAME] be given and that the facility does have this in their contingency box. DON B stated that the facility used the Interact care paths as their standard of practice related to fevers. On 5/16/14 at 12:45 PM Surveyor interviewed Licensed Practical Nurse (LPN) H via telephone. LPN H stated she was caring for Resident 3 on 3/22/14. LPN H stated there was an order to give Resident 3 Benedryl, however Resident 3 refused the medication (The note does not state why she refused the medication). LPN H stated she does not remember if she charted the refusal, however if she did not she should have. LPN H stated she also informed her supervisor, Registered Nurse (RN) D that Resident 3 had refused the Benedryl as was the facility policy. LPN H stated Resident 3 was having difficulty swallowing on 3/22/14 and would not allow staff to look into her mouth that day as she was also having difficulty opening her mouth and could not open it very far. On 5/16/14 at 6:45 PM Surveyor interviewed Family Member (FM) I. FM I is Resident 4's son. FM I stated his sister had informed him on 3/21/14 that Resident 4 was having a change in her health status. FM I stated he was informed that Resident 4 was given an antibiotic on 3/21/14 and staff at the facility thought she was having a reaction to it. FM I stated on 3/22/14 Resident 4 had changed severely since 3/21/14. FM I stated the facility staff was not concerned and the nurse on duty on 3/22/14 was told the family would like Resident 4 sent to the emergency room . FM I stated the staff nurse said the emergency room would not do anything more and Resident 4 could stay in the facility and be seen by a nurse practitioner on 3/24/14 in the facility. FM I stated her told the staff nurse the family was not comfortable with waiting and the nurse called transport at the request of the family. FM I stated he felt if Resident 4 was sent out sooner she could have been treated sooner for her illness and not been as ill as she was. FM I stated he felt if Resident 4 would not have been transported when she was she may not have made it. The facility did not call Resident 4's physician when she presented with new redness, warmth, and swelling along her jawline and below chin. Resident 4 also refused to drink more water and had difficulty swallowing water at 10:30 PM on 3/21/14. At 1:30 AM and 4 AM on 3/22/14 Resident 4's temps were elevated and the physician was not called until 8:30 AM. The physician ordered a medication and the resident refused, the refusal was not documented as to why the facility did not call the MD back to report that the medication was refused and to see if an alternate treatment should be obtained. Resident 4's family requested that Resident 4 be sent for medical evaluation on the 22nd (Saturday) and was refused by the nurse stating that the Nurse Practitioner would see her on the 24th (Monday, 2 days later). It is important to note that Resident 4 did not receive appropriate assessment and treatment for [REDACTED].

Based on interview and record review, the facility did not ensure that they provided necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, for 1 resident out of 11 reviewed (Resident 1). On [DATE] Resident 1 had returned from the hospital after surgery on her dominant arm due to a fall and fracture in the facility. On [DATE] Resident 1 began to complain of sores in her mouth that were very painful. These affected the resident's willingness/ability to take in food and fluids. Resident 1 had documented decreased food and fluid intake that was not called to the physician. On [DATE] the Nurse Practitioner met with the family and the family expressed concern over Resident 1 not eating or drinking. Orders were written to do labs due to poor fluid intake. Labs were not ordered to be done until [DATE]. The facility was documenting Resident 1's continued decreased food and fluid intakes (fluid intake was 56% of assessed need) but the care plan was not updated on how Resident 1 was to get oral fluids and foods to keep her from getting dehydrated or losing weight. On [DATE] Resident 1's family was very concerned due to the continuing significantly decreased food and fluid intake and the family wanted her to be evaluated in the emergency room (ER). On [DATE] Resident 1 was diagnosed with [REDACTED]. Findings as follows: On [DATE] Surveyor 1 reviewed the facility policy for "Food and Fluid Intake Monitoring" (no date noted). The purpose of the policy is to: 1) Identify residents who are at nutritional risk due to inadequate food and or fluid intake, 2) To provide data for nutritional and hydration assessments used in developing the residents' plan of care, and 3) To assure sufficient amount of intake for at risk residents to prevent skin breakdown, infection, weight loss and dehydration. The policy states: To assess and monitor resident's intake upon admission, quarterly and with any significant change and as needed for those residents determined to be 'at risk' by dietary personnel or by the interdisciplinary team. The procedure states that forms will be provided and placed in an intake book. Nursing personal will document the food consumption of food of all residents. Fluid intake will be documented by nursing personal on any new admission, quarterly, with any significant change or any resident determined to be at risk by the team. The interdisciplinary team will review the intake monitoring and determine when intake monitoring is no longer adequate. If hydration or nutritional intake is not adequate, a plan of care will be initiated to address these issues. The policy does not indicate the procedure to follow if a resident does not meet their assessed fluid needs, such as what to do to increase fluid intake, or when to report findings to a physician or who is responsible to assess 24 hour food and fluid intakes. Resident 1 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's "Resident Statement" form dated [DATE] indicates that she does not want CPR (Cardiopulmonary Resuscitation), or a ventilator. NG (nasal [MEDICAL CONDITION]) feeding tube was not indicated as being chosen yes or no. On [DATE] Resident 1 had a fall at the facility. Resident 1 was sent to the ER and was found to have a fractured right arm (her dominant side). Resident 1 was found with very low platelets on her [DATE] admission. Surgery to her arm was postponed until her platelets increased. Resident 1 was put on [MEDICATION NAME] 40 mg every day to assist in increasing her platelet count. Resident 1 was re-admitted to the facility on [DATE] after surgery of her right arm. On [DATE], an updated Hydration Risk Evaluation was completed. The form states that Resident 1 has 2 risk factors present, which makes her at risk for dehydration; a statement added to the form states resident is able to make wants/needs known. No signs and symptoms of dehydration noted at this time. Eats food/fluids of choice. Has water available and frequently other fluids also on bedside table. Resident 1's Nutritional care plan dated [DATE] states that her goal is to eat ,[DATE]% of all food served. The interventions listed are: Encourage fluids through out the day, monitor for signs and symptoms of dehydration, identify factors that contribute to dehydration, assist with set up of meals, nutritional reassessments by dietitian, monitor amount of meals eaten and document, encourage resident to eat all meals in dayroom or dining room. A statement added to Resident 1's care plan on [DATE] indicates c/o's (complains of) sore mouth, medications as ordered. On [DATE] a care plan entry was added which states swivel plate and curved utensils and encourage cold liquids. On [DATE], added to the care plan states dietitian to see resident regarding what she can and can't tolerate. There is no indication that this was done. Resident 1's Nutritional assessment dated [DATE] states that Resident 1 needs greater than 1400 ml of fluids a day to meet her fluid intake needs. On [DATE] an update states the Resident 1 had surgery and on [DATE] her weight was 106.8#. Intake noted to be ,[DATE]%. Very small appetite continues with intake of 25% which is below her baseline of ,[DATE]%. Continue her individualized meal plan with her favorite food items in it. An updated nutritional note on [DATE] states that (Resident 1) has been returning to baseline for eating. Currently she has a variable intake of ,[DATE]%. Baseline is ,[DATE]%. Wt is 106.8# ...She may snack ad lib...Continue her individualized meal plan. Also added on [DATE], Resident 1 wants finger foods until her arm is healed. On [DATE] another nutritional note is added that states spoke with resident and daughter and is happy with finger foods she has been getting and changed her beverages per her request, did keep within fluid restriction. The nutritional documentation does not address the significant decreased food/fluid intake (as noted below) that Resident 1 was having due to sores in her mouth. The notes do not indicate that the dietitian saw Resident 1 on [DATE]. The following are Resident 1's fluid and food intakes from [DATE] to [DATE] (B - breakfast; L - lunch; S - supper). [DATE]-B-15%, L-25%, S-90%, with a 24 hour fluid intake of 1140cc. [DATE]-B-15%, L-R (refused), S-3 bites, with a 24 hour fluid intake of 860cc [DATE]-B-25%, L-10%, S-30%, with a 24 hour fluid intake of 700 cc. [DATE]-B-50%, L-20%, S-10%, with a 24 hour fluid intake of 600cc. [DATE]-B-20%, L-10%, S-50%, with a 24 hour fluid intake of 620cc. [DATE]-B-25%, L-15%, S-bites, with a 24 hour fluid intake of 540cc. [DATE]-B-blank, L-blank, S-0%, with a 24 hour fluid intake of 780cc. [DATE]-B-R, L-10%, S-0%, with a 24 hour fluid intake of 1190cc. [DATE]-B-5%, L-blank, S-5%, with a 24 hour fluid intake of 980cc. [DATE]-B-bites, L-10%, S-5%, with a 24 hour fluid intake of 560cc. [DATE]-B-10%, L-25%, S-5%, with a 24 hour fluid intake of 860cc. [DATE]-B-5%, L-5%, S-5%, with a 24 hour fluid intake of 720cc. [DATE]-B-10%, L-5%, S-5%, with a 24 hour fluid intake of 660cc. [DATE]-B20%, L-10% then Resident 1 went to the hospital. From [DATE] through [DATE], out of 41 meals, served the average meal intake was 13% with an average of 785 cc a day for fluids. The last 7 day food/fluid average before Resident 1 was hospitalized was 5.2% of food and 821cc of fluids documented. Resident 1 had been assessed to need 1400 cc of fluids a day and Resident 1 did not meet the assessed need on any day ,[DATE] through ,[DATE], averaging only 56% of what she had been assessed as needing. The following are nursing notes related to Resident 1's appetite and fluid intake: -On [DATE] at 8:15 AM this writer informed of resident having 'nausea' and unable to eat breakfast. Saltine crackers given. At 1:30 PM ate 1 cookie and ,[DATE] peanut butter sandwich with 100 cc of lemon lime soda. At 5:30 PM Resident 1 stated she will not eat supper because afraid she will throw up. At 11:00 PM Resident took 600 cc of water but did not eat. -On [DATE] Resident 1 requested chicken broth due to not being hungry. -On [DATE] Resident 1 refused supper and just wanted to sleep. -On [DATE] Resident 1 continues to have poor appetite for supper meals. Remains on fluid restriction. On [DATE] resident continues to need some assistance with eating d/t (due to) 'weak' arms. At 9:00 PM-Appetite fair. -On [DATE] Resident does complain of sore mouth. No white areas or [MEDICAL CONDITION] noted. On [DATE] at 9:00 AM Resident 1 complained about that the corner of the right side of mouth is a little sore. At 6:45 PM Resident complains of mouth pain. Writer observed 3 areas on resident mouth. Right lateral aspect of tongue 2 areas that appear that she may have bitten her won tongue. The other area observed left posterior aspect of inner cheek. On [DATE] at 1:30 PM writer spoke with daughter regarding to resident having a sore mouth and [MEDICAL CONDITION] of feet and back today, also difficulty swallowing. At 3:55 PM c/o oral pain of sores on tongue. On [DATE] at 12 noon Dietitian notified regarding resident's sore mouth and poor appetite, taking fluids poorly also. She came in to see resident. At 4:30 PM resident 1 complained of being tired of mouth pain, and wants to feel better. [DATE] at 8:00 AM C/O's tongue being very painful. Many sores on tip of tongue resembling [MEDICAL CONDITION] now. At 6:00 PM mouth and tongue sores noted and causing direfully with po intake soft foods/fluids encourage resident remains below fluid restrictions. -On [DATE] Ams, Resident 1 was having difficulty swallowing sores noted on tongue. At 7:45 PM ate only bites for supper and 150 cc of Kemps (nutritional supplement). -On [DATE] at 6:00 PM Resident 1's mouth/tongue sores treated as ordered and continues to have pain and difficulty swallowing encourage po intake as safe/able -On [DATE] at midnight Resident 1 voice is raspy and weak d/t sores mouth/throat continue on med for this. -On [DATE] Resident 1 continues to express mouth discomfort d/t sores voice remains hoarse. At 12:30 PM Resident 1 coughed and gurgled some with sips of water afterward seemed to be holding water in mouth (when pills were given). At 5:45 PM Resident 1 does state tongue very sore-doesn't want to eat or drink. -On [DATE] at 2:00 AM voice very weak like a raspy whisper Tongue has open sores will take 30 cc of water when offered. At 7:00 AM Resident 1 c/o pain in mouth multiple sores coating tongue and cheeks. At 10:30 AM Resident 1's family expressed concerns regarding Resident 1's treatments. Family wanted Resident 1 evaluated due to advanced sores in mouth and tongue and throat. -On [DATE] at 12:50 states, "...ER evaluation today d/t resident having so much difficulty swallowing and stating "I feel so miserable I'll try anything including going to the hospital..." The documented nursing notes do not address a plan of action for Resident 1 not getting continued proper fluid/food intake, nor do any notes indicate that the MD or NP was informed on what Resident 1's food/fluid intake had been. On [DATE] NP E saw Resident 1 and documented that Resident 1 was complaining of her tongue being sore and her oral mucosa and tongue with a burning sensation that was felt secondary to her [MEDICAL CONDITION]. An antifungal was ordered to treat her mouth complaints. On [DATE] NP E saw Resident 1 and daughter and documented in his note states, "It should be noted that this provider was called over the weekend regarding the patient as she was continuing to struggle with oral pain, burning pain in her mouth, and continuing to have [MEDICAL CONDITION] reported within the mouth and also not was not eating or drinking well. The family was reported to be quite upset about the patient's continuing lack of appetite and lack of fluid intake..." The note continues on to state, "We asked (Resident 1 name) to rate her pain for us today and she states that at this point in time as long as she is not trying to drink or eat anything she does not have pain but she does state that when the pain is there it is a burning pain. It is, as the Patient states, nearly intolerable pain and she feels it both in the mouth but she also points to the right side of her face to indicate the location of her pain..." New orders were received to treat mouth sores and lab work was ordered because of the poor fluid intake and followed closely. Lab work was ordered, but was not ordered to be done, until [DATE]. On [DATE] Resident 1's primary care physician was in to see Resident 1. Resident 1's physician's progress note indicates that he discontinued Resident 1's fluid restriction as the patient is not taking in fluids well and wished to encourage fluids. The note does not indicate that Resident 1's primary care physician was made aware of significantly decreased food, nor does it indicate what plan is put in place to get Resident 1 to increase her food and fluid intake. A review of Resident 1's Hospital History and Physical dated [DATE] states that Resident 1 was given IV [MEDICATION NAME] for her heart failure/[MEDICAL CONDITION] fib and [MEDICATION NAME] IV for her [MEDICAL CONDITION] sores in her mouth, and 1 unit of platelets for low platelets. Resident 1's [DIAGNOSES REDACTED]. Resident 1 was admitted to the hospital because of her dehydration and other problems. While in the hospital, gentle [MEDICATION NAME] was done because of the patient's findings of [MEDICAL CONDITION], a beta blocker was added and the patient continued to deteriorate and became unresponsive. Resident 1 expired on [DATE]. On [DATE] at 2:30 PM Surveyor interviewed NCC D regarding Resident 1 with decreased food and fluid intake. NCC D stated, "We would normally update the physician or nurse practitioner in each case. We were in contact with the NP almost every Tuesday and Thursday. (That is when the NP did rounds at the facility). OT was seeing her for feeding at mealtimes. We would discuss aggressive or palliative care with the families when a condition change would occur. (Resident 1) was a DNR." Surveyor asked NCC D what the procedure is for assessing 24 hour intake. NCC D stated, "After a couple of occurrences (low intake) we would monitor and give the doctor or NP a weekly update when not meeting needs." Surveyor asked NCC D where any documentation would be into any discussion with the MD, NP, family, and/or Resident 1 regarding palliative care or a change of condition as it relates to decreased intakes. NCC D took the record for review and did not give Surveyor any additional information regarding the decreased intakes of Resident 1. The facility did not provide Surveyor with any additional information regarding Resident 1. On [DATE] at 3:00 PM, Surveyor interviewed NP E (Nurse Practitioner) regarding Resident 1's condition. NP E stated that Resident 1 had multiple things going on with her. Resident 1 just had surgery, began new medications and mouth sores complicated issues. NP E stated the facility did call him often regarding the mouth sores as Resident 1 was complaining and NP E remembers adding medications to address that issue. NP E stated that the facility called him and he went to see Resident 1 often but does not remember the facility specifically reporting that Resident 1 was not eating or drinking well or that Resident 1's intake had significantly declined. NP E stated that he would have a discussion about tube feedings or IV's with the family in these situations but does not specifically recall that a conversation about IV's or tube feedings with Resident 1 or the family. NP E was asked by Surveyor what his expectation would be if a resident had decreased food and fluid intake from their baseline. NP E stated that he would expect that the facility would do a set of vital signs, ask the resident "why" they aren't eating or drinking, assess skin turgor, look in their mouth, and take blood pressures. NP E added that he would expect a report of the intake and outputs then NP E would order labs to see what they are and then provide a plan of action. On [DATE] at 1:30 PM Surveyor interviewed PCP F (Primary Care Physician) regarding Resident 1. PCP F was asked if he was aware of Resident 1's decreased oral intake of food and fluids. PCP F stated that he reviewed Resident 1's medical record and did not find that he was informed of her decreased oral intake.