Every finding on record at Rennes Health and Rehab Center-Rhinelander

Based on observations, interviews and record reviews, the facility did not ensure staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not transport soiled laundry in a sanitary manner. This has the potential to affect the 17 residents that live between R90's room and the dirty linen storage area.The facility did not transport clean linen from laundry through the facility to patient's rooms on a hanging rack. This has the potential to affect all 35 residents whose linen at minimum is laundered and transported by the facility. Registered Nurse (RN) F did not practice hand hygiene or wear gloves when giving a subcutaneous injection to a resident (R) (R32).Certified Nursing Assistant (CNA) H delivered fresh water cups into R10's and R73's room and then into R7's and R24's room without practicing any hand hygiene between rooms and after handling dirty water cups. CNA G did not perform hand hygiene after handling contaminated cups and delivering clean cups of water to R13, R1, R63, and R29. This is evidenced by: Facility policy titled, Departmental (Environmental Services)-Laundry and Linen dated January 2014, states in part: Bagging and Handling Soiled Linen 1. All soiled linen must be placed directly into a covered laundry hamper which can container moisture. 3. Place any linen saturated with blood or body fluids into a leak- resistant bag before placing it into the hamper. Washing Linen and Other Soiled Items. 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. Note: Policy provided did not directly address how staff on unit should handle soiled linen and clothing. According to the CDC Appendix D titled, Linen and Laundry Management, dated March 19, 2024, states in part: Never carry soiled linen against the body. Always place it in the designated container. Bag laundry where it originates. Example 1 On 12/20/25 at 7:33 AM, Surveyor was by the elevator on first floor when Surveyor observed Laundry Aide (LA) I exiting the elevator pulling a large cart of uncovered clean resident clothing. Some clothing was hanging, and some was folded on the base of the rack; nothing was covered. On 12/10/25 at 7:46 AM, Surveyor interviewed LA I who stated, That is the boo boo I did. I didn't cover this (the hanging rack) when I went out. I hoped you hadn't noticed. LA I stated the rolling rack should have been covered. LA I stated she's been here since 1:00 AM because she wants to get home before the weather. On 12/10/25 at 8:12 AM, Surveyor interviewed Environmental Services Manager (ESM) D during tour of laundry. Surveyor asked her expectations. ESM D stated she expects linen is covered when it is being transported. ESM D was informed of Surveyor's observation. Surveyor asked ESM D for a policy for transporting linen. On 12/10/25 at 10:47 AM, ESM D told Surveyor, I do not think we have any policy related to transporting linen clean or dirty. I am working on policies now, trying to get them organized and updated. Example 2 On 12/10/25 at 9:52 AM, Surveyor observed CNA J leave R90's room with a bag of dirty linen. CNA J dragged the linen down the hall and around the corner to where the dirty linen and clothes are stored before they go to laundry. On 12/20/25 at 10:58 AM, CNA J showed Surveyor where the linen chutes were. CNA J stated linen is bagged in the room and brought to the dirty area to be stored. CNA J stated eventually covered carts are taken to the chute and bags are sent down to laundry. Surveyor asked what if the bag is too big. CNA J stated that we usually try to do multiple small but otherwise it has to be taken down in a covered cart. Surveyor asked how the linen gets from the resident's room to the holding spot. CNA J stated it is bagged and carried. Surveyor asked if it is carried off the floor or dragged on the floor. CNA J stated no, the dirty linen is never dragged. Surveyor asked CNA J how the linen was carried when Surveyor saw CNA J with the linen from R90's room. CNA J stated, Oh, I dragged it. I shouldn't have. On 12/11/25 at 11:18 AM, Surveyor interviewed Assistant Director of Nursing (ADON) C, the facility's Infection Preventionist, who stated dirty laundry should not be dragged down the hall. ADON C stated we do not want cross contamination; dirty clothes and linen should be bagged and tied closed. ADON C stated dirty linen should not be dragged or carried unbagged. Example 3 The facility's procedure document titled, Subcutaneous Injections, revised April 2007, states in part, .Steps in the Procedure. 1. Perform hand antisepsis. 2. Put on gloves. 3. Place the equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached, 4. Select injection site. On 12/10/25 at 9:10 AM, Surveyor observed RN F draw up 3 units of Aspart Insulin and prime R32's glargine insulin pen and set the pen to 12 units. RN F entered R32's room with insulin, cleared off spot to set insulin on R32's bedside table, explained procedure to R32, then injected both syringe and injector pen insulin into R32's L abdomen without putting on gloves or practicing hand hygiene prior to giving injections. On 12/10/25 at 9:13 AM, Surveyor interviewed RN F about hand sanitization and using gloves when administering insulin. RN F stated she had forgotten. On 12/11/25 at 8:21 AM, Surveyor interviewed ADON C, who reported the expectation would be hand hygiene be performed and gloves be worn during an injection. Example 4 The facility's policy statement titled, Handwashing/Hand Hygiene, revised August 2015, states in part, .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: . l. after contact with objects (e.g. medical equipment) in the immediate vicinity of the residents. On 12/09/25 at 11:27 AM, Surveyor observed CNA H pass fresh water to residents. CNA H entered the room of R55 and R59 carrying fresh water for both residents, then took their used water cups out of room and set them on the cart. CNA H then took fresh water cups into R10 and R73 without practicing any hand hygiene between rooms and after handling dirty water cups. Surveyor observed CNA H do this for 2 more rooms, R7 and R24, and did not observe CNA H practice any hand hygiene. On 12/09/25 at 11:32 AM, Surveyor interviewed CNA H, who stated, I'll be honest with you, I am bad at that. CNA H was not sure when to perform hand hygiene but reported the facility did provide education on it. On 12/10/25 at 9:51 AM, Surveyor observed CNA G deliver fresh water to residents and remove the used water cups without practicing hand hygiene after handling contaminated cups and delivering clean cups of water for R13, R1, R63, and R29. On 12/10/25 at 9:58 AM, Surveyor interviewed CNA G. CNA G stated she was unaware she needed to use hand hygiene after contact with used water cups and performs hand hygiene before passing water to all the residents on the hall and not in between each resident or rooms. On 12/11/25 at 8:23 AM, Surveyor interviewed ADON C, who reported the expectation would be hand hygiene be performed after handling resident's used dishes and before handling clean cups and entering another resident's room.

Based on observations, record reviews and interviews, the facility did not ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 out of 1 resident (R) reviewed. (R90)Nurse did not measure enteral feeding appropriately and if not questioned, she would have had too much enteral feeding in the tube feeding set up.Nurse did not prime the tubing before connecting the feeding tubing to the J-G tubing, resulting in the air in tubing to be pushed into R90's stomach.Findings include:Surveyor asked for all policies that pertain to tube feeding. Surveyor received two polices Maintaining Patency of a Feeding Tube (Flushing), revised 2012, and Administering Medications through an Enteral Tube, revised May 2014. Neither policy addresses setting up and administering a tube feeding.The American Society for Parenteral and Enteral Nutrition, Enteral Nutrition Practice Recommendations indicate that priming the tubing is a standard procedure. The purpose is to remove air from the line to prevent air from entering the patient's stomach or intestines which can cause discomfort or other complications.R90 was admitted to the facility on [DATE] with history of pneumonia and the goal of getting stronger and recovering. R90 has only been at the facility one week and does not have a fully completed Minimum Data Set (MDS). Surveyor interviewed R90; he is alert and oriented times 3 and appeared cognitively intact. R90's physician order for his enteral feeding via a J/G peg tube, dated 12/9/25, states: Mix 60ml sterile water with 350 mL Jevity 1.5 via bolus feeding, four (4) times per day. Feeding times: 0600, 1000, 1400 and 1800. Give 60 mL sterile water before and after each feeding. Additional free water with medications. Four Times A Day AM, Noon, PM, HS.On 12/10/25 at 9:48 AM, Surveyor began the observation for the set up and administration of R90's tube feeding to receive medication via his tube feeding. Nurse Manager (NM) K was with during the treatment. At 10:02 AM, Registered Nurse (RN) F completed hand hygiene and put on a gown and gloves. RN F checked for correct tube placement and administered medications appropriately. When completed RN F started to set up enteral feeding. RN F stated the bag is changed on night shift, and Surveyor observed it labeled appropriately. RN F poured 60 ml of water directly into the feeding bag. RN F then opened one bottle of Jevity (237ml) and added it. RN F then looked at NM K and said, It's 350 ml of feeding so I don't need this whole thing. Wait how much for 350cc, how should I do this? During this conversation of determining how much Jevity was still needed, R90 stated, 120ml, you need 120ml. RN F turned and looked at the bag. Yeah, where is that on the bag? I can fill it to (pause to look), well it isn't totally marked but . RN F trailed off speaking and looked at NM K. NM K stated you should use a graduate. RN F poured 120 cc of Jevity into the graduate and turned to pour it into the feeding bag. After questions RN F realized that she was going to have 357ml of feeding and it is ordered for 350ml. RN F sat the graduate back on the table, took the syringe and pulled off 7ml and then poured remaining Jevity into the bag. RN F proceeded to connect the tubing and open the flow. RN F did not prime the tubing that was full of air. The last feeding ran dry and emptied tubing completely.On 12/10/25 at 10:42 AM, Surveyor interviewed RN F about measuring the Jevity. RN F stated she should have used the graduate the whole time, but it works to just pour it in the bag. Surveyor asked if there is anything else that needs to be done when setting up a tube feeding with the bag or tubing. RN F stated the bag and tube are all connected so not really. RN F stated I just connect it, there is nothing special. Surveyor asked what about the air in the tubing, where does it go. RN F stated, Oh, I should have primed it, I see.On 12/10/25 at 10:44 AM, Surveyor interviewed NM K who stated tubing should be primed.

Based on observation, interview, and record review, the facility did not ensure the residents' environment remains as free of accident hazards as possible. The facility did not ensure staff followed supervision of residents when needed to prevent accidents, which affected resident (R) R1 and had potential to effect 5 other residents.Facility staff did not stay with R1 during the time R1 was in a spa bath. Staff intermittently checked on R1 during the spa bath, and after approximately 2 hours, staff found R1 in the spa tub unresponsive, which required facility to call 911 for Emergency Medical Service (EMS). EMS found R1 with body temperature of 106 degrees Fahrenheit (F), Blood Pressure (B/P) 116/96, Respirations (R) 10 breaths per minute requiring intubation for breathing, and Pulse (P) 59 and increasing to 124 beats per minute (bpm). R1 had first degree burns (reddened skin) noted to be greatest on his right upper extremity, over his abdomen, and a second degree burn to his left calf, skin was blistered and did break on transport to the ER, second degree burn to left upper thigh, and right buttocks blister. R1 was transported to hospital ER and later transferred to an Intensive Care Unit (ICU) at a higher-level of care hospital.The facility's failure to monitor water temperature checks in the spa tub and supervise R1 during R1's spa bath created a finding of immediate jeopardy that began on [DATE]. Surveyors notified Nursing Home Administrator (NHA) A, Director of Nursing (DON) B, and Regional Nurse of the immediate jeopardy on [DATE] at 11:08 AM. The immediate jeopardy was removed on [DATE] however, the deficient practice continues at a severity/scope of E (Potential for Harm/Pattern) for residents R2, R3, R4, R5, R6, who use the spa bath and as the facility continues to implement its action plan. Findings include:According to Nature Reviews Disease Primers ([NAME], M.G., van [NAME], M.E., [NAME], M.A. et al. Burn injury. Nat Rev Dis Primers 6, 11 (2020). https://doi.org/10.1038/s41572-020-0145-5), Burns that affect the uppermost layer of the skin (epidermis only) are classed as superficial (first-degree) burns; the skin becomes red, and the pain experienced is limited in duration. Superficial partial-thickness (second-degree) burns (formerly known as 2A burns) are painful, weep, require dressing and wound care, and may scar, but do not require surgery. Deep partial-thickness (second-degree) burns (formerly known as 2B burns) are less painful owing to partial destruction of the pain receptors, drier, require surgery and will scar. A full-thickness (third-degree) burn extends through the full dermis and is not typically painful owing to damage to the nerve endings, and requires protection from becoming infected and, unless very small, surgical management. Finally, a fourth-degree burn involves injury to deeper tissues, such as muscle or bone, is often blackened and frequently leads to loss of the burned part. Although superficial and superficial partial thickness burns usually heal without surgical intervention, more severe burns need careful management, which includes topical antimicrobial dressings and/or surgery. Importantly, burns are classified as either minor or major. A minor burn is usually a burn that encompasses <10% of the total body surface area (TBSA), with superficial burns predominating. By contrast, the burn size that constitutes a major burn is not commonly well-defined; some guidance to classify severe burn injuries are: >10%TBSA in elderly patients. The uniqueness of a severe or major burn injury is anchored in the body responses to it. After the injury, an immediate systemic and local stress response is triggered that, unlike sepsis or trauma, does not recover quickly. Severe burns cause a complex pattern of responses that can last up to several years after the initial insult. In general, immediately after the insult, an inflammatory response is triggered to promote the healing process. However, in severe burns, this inflammatory process can be extensive and become uncontrolled, leading to an augmented inflammation that does not induce healing but rather causes a generalized catabolic state and delayed healing. This response is almost unique to burns and is referred to as the hypermetabolic response; it is associated with catabolism, increased incidence of organ failure, infections and even death. According to The Effect of Age and Mitigation Strategies During Hot Water Immersion On Orthostatic Intolerance And Thermal Stress ([NAME] J. Steward, [NAME], [NAME] D. [NAME], [NAME] E. [NAME], [NAME] Hill, [NAME] J. A. [NAME], C. [NAME] Thake, [NAME]. First published: 27 February 2023 https://doi.org/10.1113/EP090993), It is well established that thermal intolerance ([NAME] & [NAME], 1987) and orthostatic intolerance ([NAME] et al., 2017) are altered by age. In response to an orthostatic challenge following passive heating, older adults have been shown to have a greater reduction in cerebral blood flow and slower corrections in blood pressure when compared with younger adults (Lucas et al., 2008). Accordingly, characterization of the safety and tolerability of hot water immersion protocols should be done separately for different age groups. Surveyor reviewed manufacturing instructions for facility's spa tub titled, MASTERCARE MB-80R Operation Manual, which states in part: . Page #10: In case of a resident emergency during a bath; open drain, then open door and remove them even if the tub is full. Seek help immediately. https://www.manualslib.com/manual/2243728/Mastercare-Mb-80r.html?page=10#manual R1 was admitted to the facility on [DATE] with diagnoses including, in part, chronic obstructive pulmonary disease, left bundle branch block, bipolar disorder with moderate depression, COVID-19 respiratory disease, urinary tract infection (UTI), hypertensive chronic kidney disease stage 1-4, epigastric pain chronic, flaccid neuropathic bladder, anxiety, hyperlipidemia, insomnia, peptic ulcer, benign prostatic hyperplasia, right artificial hip and knee joint. R1's Minimum Data Set (MDS) assessment, dated [DATE], identified on admission that R1 had a Brief Interview for Mental Status (BIMS) score of 14/15, indicating intact cognition. The MDS assessment also identified R1 required partial/moderate assist with bathing/showering self. R1 was partial/moderate assist with bathing/shower transfers. Surveyor reviewed R1's care plan initiated on [DATE] and revised on [DATE]:-Dressing and grooming with assistance as needed.-Revision on [DATE], Toileting: Assist of one with 2 wheeled walker (ww). Can alert staff to toileting needs. Continent of bowel and has a foley catheter for bladder.-Revision on [DATE], Transfer Assist of one with 2 ww, and bed mobility: assist of one. Surveyor reviewed R1's physician orders:-Atorvastatin 20mg at bedtime. Received last on [DATE] at HS (hour of sleep).-Hydrochlorothiazide 12.5mg daily in the AM. Received last on [DATE] in AM.-Aspirin 81 mg daily in the AM. Received last on [DATE] in AM.R1's documented vital signs on [DATE] at 4:28 PM, B/P 153/94, P 74, R 18, T 97.5 F, Oxygen Saturation (O2 sat): 98%, and weight 255 pounds. Surveyor reviewed R1's progress notes, which stated, -On [DATE] at 8:33 PM, Weekly assessment: Resident at facility for LTC [Long Term Care]. Alert and oriented x 2-3. No confusion noted today. Able to make needs known. Chronic pain managed with scheduled and prn (as needed) oxycodone. Oral mucosa pink and moist. Skin warm and dry. Fluids available at bedside. Lung sounds clear. Respirations even non labored. Some c/o (complaints of) cough. Bowel sounds active x 4. Abdomen soft non tender. Foley patent draining clear yellow urine. Mild edema noted to BLE [Bilateral Lower extremity]. Pedal pulses present. In wheelchair (w/c) at time of assessment. Received spa bath tonight. Able to self-propel in w/c throughout facility. Fluids encouraged and available on bedside table. Will continue to monitor. Surveyor reviewed EMS report form [DATE]:-EMS received an emergency phone call from the facility on [DATE] at 9:16 PM reporting that R1 is unresponsive, and it is unknown if there is any injury after being in a spa tub.-EMS arrived at the facility on [DATE] at 9:21 PM. EMS assessed and reported that R1 was found with an unmanaged, but patent airway, unlabored respirations at 10, strong carotid pulse present, pupils constricted, possible 1st degree burns noted to R1's backside, possible 2nd degree burns to R1's leg per paramedic. R1 was reported by staff to have been in the hot tub for about 2 hours and one staff member stated that R1 was last seen normal around 8:55 PM, about 30 minutes prior to history of events being obtained. A staff member was coming to get R1 out of the hot tub and found R1 unresponsive, and hot tub was drained and 911 called. EMS arrived on scene and found R1 as stated. Paramedic assessed carotid for pulse, and R1 was breathing spontaneously. R1's airway was then manually managed and provided a Bag Valve Mechanical (BVM) used to assist with respirations as R1's respirations appeared shallow and less than 12 bpm. 28 French (Fr) Nasopharyngeal Airway (NPA) inserted. R1 placed on 4 lead and appeared to be bigeminy (a cardiac arrhythmia where a normal heartbeat is followed by an abnormal one, creating a regular pattern of two beats). R1's pupils assessed and found to be constricted, staff confirmed R1 is on opioids, and R1 was given Narcan (medication to reduce the effects of narcotics). R1 was moved to cot and found to have extremely hot extremities, with erythema (redness of the skin) present. R1 was on cot, pupils increased in size, and breathing appeared to pick up. R1 switched to a non-rebreather (NRB) with 15 liters of oxygen. R1's temp (temperature) was found to be 106 degrees F. Cold packs immediately applied to R1. R1 given an Intraosseous (I/O) (specialized needle inserted into the bone's marrow cavity) Narcan and saline. R1 respirations noticeable to 24 bpm and pupils increased in size some more. R1 arrived at hospital and R1's blood pressure began to drop. Care handed over to attending physician in ER. R1's hospital report from [DATE] stated: .-R1 arrived in hospital on [DATE] at 9:42 PM. emergency room (ER) diagnoses of R1 were hyperthermia (elevated body temperature), UTI (Urinary Tract Infection), and altered level of consciousness. R1 was disoriented to place, time, situation, and person. R1 was noted to be hyperthermic, rectal temperature read 106.2 degrees F. He received cold fluids, ice packs in axillary (under arm), groin, and neck. R1 had B/P of 160/70, pulse 124, temp 102, respirations 14, and O2 97% ON 2 L. Tachycardia (Elevated Heart Rate) present, R1 arrived with rather noisy breathing from secretions. RT (Respiratory Therapist) was eventually able to suction him and his breathing did clear. R1 has reddened skin noted to be greatest on his right upper extremity, over his abdomen, and a burn to his left calf, skin is blistered and did break. R1 was quite hyperthermic and in his altered mental status that has not improved after his temperature has improved to below 102. Patient will require admission as he will need ICU care. Do not have the capability to admit him at this facility. Transfer to another hospital. Accepting MD [Medical Doctor] will accept the patient in transfer to the ICU for further evaluation and treatment. Lactic acid of 5.0, repeat of 2.7 (normal lactic acid is 0.5-2.0 elevated lactic acid can indicate organ failure and is a medical emergency) was concluded. Hospital will monitor R1's temperature which continued to improve but his mentation did not improve. His heart rate was starting to decline from 130 to 120s. He had stable blood pressures. With no improvement of his mentation as he has not responded so decision was to intubate R1 and send to higher level of care.-Vitals throughout the stay were: [DATE] at 11:25 PM, 149/66, HR (heart rate) 130, O2 98 % on 15 L (liters) nonrebreather maskXXX[DATE] at 11:35 PM, 165/71, HR 130, 98% on O2XXX[DATE] at 12:45 AM, 97/54, HR 95, 99% on O2XXX[DATE] at 2:20 AM, 84/48, HR 80, 100% on O2. Of note, your blood vessels remain dilated for a while. This continued vasodilation, combined with the blood pooling in your extremities, can cause a drop in blood pressureR1 has continued on propofol drip (medication to sedate a person) after intubation. R1 has received IV fluids. He received 2 grams of Rocephin (antibiotic) in his he does have signs of urinary tract infection. I/O placed in the field. 15L nonrebreather. EMS stated they gave Narcan in the field due to pinpoint pupils.Hospital found:R1 suffered severe redness to entire body from shoulders down to feet. Second degree burn blister opened to right back of ankle measuring about 1cm long and 0.5cm (centimeter) wide, about 4cm long second degree burn to R1's scrotum, second degree closed burn blisters formulated on R1's buttocks with about 2cm open blister on the right gluteal maximus. 8cm x 8cm open blister on left lateral leg.R1 transferred to a higher-level care hospital on [DATE] at 2:20 AM.On [DATE] at 10:29 AM, Surveyor observed spa room down 400-wing. Surveyor did not observe a call light in the spa tub room. Surveyor did not observe a call light cord long enough to reach to the spa tub room from the shower room.On [DATE] at 10:36 AM, Surveyor observed spa room down 100-wing. Surveyor did not observe a call light in the spa tub room. Surveyor did not observe a call light cord long enough to reach to the spa tub room from the shower room.On [DATE] at 4:11 PM, Surveyor interviewed CNA D and asked if CNA D could walk through the events of [DATE]. CNA D reported that CNA D placed R1 in the spa tub around 7:10 PM. CNA D reported to Surveyor that CNA D was training CNA E who was a new CNA to the facility. CNA D and CNA E placed R1 in the spa tub, ran the water until tub filled, and then turned off the water. CNA D reported that CNA D and CNA E had to help other residents, so CNA D shut the water off and then left R1 in the tub to soak. CNA D reported that around 7:50 PM, CNA D went into spa room to check on R1 and asked R1 to get out of tub. R1 refused and stated, No I just got in here. CNA D then left R1 again. CNA D reported that around 8:10 PM CNA D sent CNA E the trainee in to check on R1. CNA D reported that CNA E had come out and said R1 did not want to get out yet. CNA D reported that at around 8:30 PM, CNA D went back into spa room to check on R1 and again R1 stated, No. CNA D reported at 8:55 PM, CNA D, CNA E (trainee), and CNA O from agency went in to try and get R1 out of the tub. CNA D reported that CNA D observed R1 had a towel rolled behind R1's neck, eyes were closed, and R1 was laid back in the tub. CNA D stated, [CNA O] went over to [R1] and told [R1] that it is time to get up and get out. [R1] did not open eyes as he was resting. CNA D, CNA E (trainee), and CNA O all left the spa room. CNA D reported at 9:00 PM, CNA D reported to Licensed Practical Nurse (LPN) M that R1 would not get out of the tub, and it has been almost two hours that R1 has been in the spa tub. CNA D asked CNA N if CNA N could go try to get R1 out of spa room and Registered Nurse (RN) J stated, I am going over on 100 wing now to go get R1 out of the tub. CNA D reported around 9:15 PM, CNA Q went into spa room with RN J to help get R1 out of spa tub. CNA D stated to Surveyor, After the incident was over staff were talking and CNA Q said that the water was still running when R1 was found in the tub unconscious. Surveyor asked CNA D if R1 can reach the controls to the left or stand up to drain the tub. CNA D stated, I guess I am unsure; we usually have to fill the tub for him and assist some. Surveyor asked CNA D if it is normal process to leave R1 in tub alone. CNA D reported to Surveyor it is not common practice to leave any residents in tub alone but R1 is kind of an exception. Surveyor asked CNA D if R1 was assessed to safely be left alone in the spa tub. CNA D reported that CNA D was unsure, but staff have always done that for as long as I can remember. CNA D reported that the facility does not have many spa baths so is unsure if anyone assessed R1 for safety in spa room alone. Surveyor asked CNA D if a call light was left in place in case R1 needed assistance while alone in the spa room. CNA D reported that CNA D did not. CNA D reported to Surveyor that about a month ago at a CNA meeting CNA D brought it up to Staffing Coordinator (SC) H, who coordinates the meetings monthly, that R1 was taking very extensive baths in the spa room and CNA D was concerned. CNA D reported SC H was going to bring this concern up to R1's Case Manager (CM) R on the unit but was unsure if it was taken care of. Surveyor asked CNA D if CNA D has had any training on the use of the spa tub. CNA D reported that CNA D has been working with the facility for about 5 years and has never received any training on the spa tub. Surveyor asked CNA D if CNA D received any education regarding the incident and any education on the spa tub after the incident on [DATE]. CNA D stated, I did not receive any education right after, but facility sent texts today on [DATE] at 12:57 PM, regarding spa baths are to only be 30 minutes long and water not to exceed 95 degrees Fahrenheit. Then 45 minutes later another text came through that regarded not leaving anyone alone in the spa room, risks versus benefits of the spa tub, and water not to exceed 102 degrees Fahrenheit. Surveyor asked if CNA D has worked since Monday night on [DATE]. CNA D reported CNA D worked the next two nights on [DATE] and [DATE] night shifts. CNA D reported that there was some kind of paper education floating around while CNA D was on shift on [DATE] that evening but CNA D did not get a chance to review it yet. Surveyor asked how hot the water gets in the spa tub. CNA D stated, I always dip my hand in to make sure it's not too hot, but that water does get pretty hot. I just know that R1 likes it warm. CNA D reported she did not check the reservoir temperature of bath before placing R1 in the tub. On [DATE] at 10:02 AM, Surveyor reinterviewed CNA D. Surveyor asked CNA D if CNA D had left the water running when leaving the first time with CNA E. CNA D reported that CNA D had sent trainee out to help CNA N while CNA D was filling the tub with water and CNA D stayed with resident till the tub was filled. CNA D reported CNA D turned water off before exiting the spa room. CNA D reported to Surveyor that CNA D left 2 washcloths and a towel with R1. R1 likes to wash himself in the tub with his bodywash. Surveyor asked what the temperature of the bathtub was when CNA D left R1 in tub. CNA D reported the temperature was 101 degrees F. Surveyor stated to CNA D that CNA D reported earlier that CNA D didn't check temperature of the bath water before leaving. CNA D reported that CNA D remembered now that it was checked. CNA D reported that the drain has a slow leak so sometimes R1 will ask for a refill after about 45 minutes but CNA D reported R1 did not ask this time while in the spa tub, but CNA D made sure that the tub drain was closed. Surveyor asked CNA D if CNA D thought R1 could use his own arms and hands to reach the controls of the tub. CNA D reported that CNA D is unsure. CNA D reported R1 could help take off clothes, stand, and pivot to get into tub but has never seen R1 reach for controls. Surveyor asked CNA D about facility offering education on the spa tub and what has been educated. Education sheet came out on [DATE] at night from charge nurse educating if approved to bathe alone, safety belt will be utilized, if resident refuses safety belt, then staff are to stay with residents for supervision during spa. CNA D reported that on Friday afternoon CNA D received more education using the spa safety belt and the door hatch.On [DATE] at 4:33 PM, Surveyor interviewed Staffing Coordinator (SC) H on the phone due to SC H being out on sick leave. Surveyor asked if SC H remembers CNAs bringing up their concern for R1 staying in the spa tub too long. SC H remembers vaguely but it was brought up in the August CNA meeting. SC H reported SC H brought the concern up to CM R and CM R stated, [R1] likes to stay in spa tub for long periods due to back pain. SC H reported being unsure if anything was addressed. SC H remembers a different CNA bringing this up at the meeting, which in turn SC H stated, [R1] cannot be left alone in the spa tub at all. Surveyor asked SC H if R1 had received a formal assessment to assess the safety of R1 using the spa tub and being left alone. SC H could not recall but common practice is no one left alone in the spa tub.On [DATE] at 6:37 PM, Surveyor interviewed CNA E (trainee) and asked CNA E to explain the events on Monday [DATE] with R1 in the spa room. CNA E reported working her second shift and was new at the facility. CNA E reported CNA E and her trainer, CNA D, went into spa room around 7:00 PM. CNA D quickly showed CNA E how to turn on spa tub and then CNA E and CNA D proceeded to place R1 in spa tub and began filling tub with water. CNA E reported that CNA D told CNA E that they both needed to go take care of other residents so CNA E and CNA D left the spa room with water still running so that R1's tub could fill. CNA E reported that later about 45 minutes to an hour CNA D asked CNA E to go into the spa room and try to get R1 out of the spa tub. CNA E stated to CNA D, I don't feel comfortable doing this on my own as I am not familiar with the spa room. CNA D told CNA E that CNA E would be fine to just go check on R1. CNA E reported that when CNA E walked into the spa room it was extremely warm in there. CNA E observed the temperature in the room on the wall to be at 79 degrees Fahrenheit. CNA E reported that the water was still running and looked like it was getting high. CNA E observed bubbles in the spa tub and R1 resting with eyes closed leaning back in tub. CNA E asked R1 to get out of tub, and R1 didn't open eyes but said, No. CNA E exited spa room and went to update CNA D, and CNA D then gathered another CNA so that all 3 of the CNAs would go try to get R1 out. CNA E reported that CNA D, CNA E,and CNA O went in to try and get R1 out of the tub a while later. CNA E reported that CNA E observed R1 had a towel rolled behind R1's neck, eyes were closed, and R1 was laid back in the tub. CNA E reported CNA O went over to R1 and told R1 that it is time to get up and get out. R1 did not open eyes as he was resting. CNA E, CNA D, and CNA O all 3 left the spa room. CNA E reported that CNA E left at 9:00 PM as shift was over. Surveyor asked CNA E if CNA E received any training on the spa room or any education regarding the incident on [DATE]. CNA E reported to Surveyor that CNA E has not received any training on the spa room or the incident until this afternoon on [DATE] through a text that I acknowledged what is being educated. CNA E stated, I did not feel comfortable going into the spa room by myself as this spa bath was my first one performed at the facility, and I did not receive any education on spa tub use. On [DATE] at 2:59 PM, Surveyor interviewed CNA N and asked if CNA N knew any information regarding incident involving R1 in the spa tub. CNA N reported to Surveyor that CNA D, CNA E (trainee), CNA O, and CNA N were all splitting 200 hall and helping one another out. CNA N reported to Surveyor that CNA N took R1's vitals before dinner time and vitals were within normal range. CNA N stated, I spoke with [R1] about the weather, and he was excited about his spa that staff were going to give him after dinner. CNA N reported that R1 seemed ok but also seemed extra tired than normal. CNA N stated, I remember [CNA D] coming up to me at some point and asking me to check in on [R1] to see if I could get [R1] out of the tub as [R1] was refusing to get out. CNA N reported when CNA N walked into spa room, there was a whole team in there and a nurse had yelled for CNA N to get out. CNA N reported that CNA N has no other details as CNA N had little involvement. Surveyor asked CNA N if CNA N has received any education regarding the incident and the dos and don'ts of a resident receiving a bath in the spa room. CNA N reported that CNA N has not received any training on the spa bath or any education on the incident from [DATE] involving R1 as of [DATE].On [DATE] at 2:53 PM, Surveyor interviewed Certified Nurse Assistant (CNA) P and asked if CNA P knew any information regarding the incident involving R1 in the spa tub. CNA P reported hearing about someone being left alone but that CNA P was not involved. Surveyor asked CNA P if it is a normal process to leave residents in the spa room alone. CNA P reported the facility kind of has a relaxed policy regarding the spa usage. Surveyor asked CNA P to explain what relaxed policy means. CNA P reported there just isn't any direction regarding the spa use. Surveyor asked CNA P if CNA P has had any training lately regarding the incident from Monday night [DATE]. CNA P reported that CNA P was not trained in using the spa. CNA P reported the last education or training provided by the facility had been last month at a CNA meeting where they were educated on care cards and skills lab. Education is also provided annually.On [DATE] at 3:49 PM, Surveyor interviewed Maintenance Director (MD) I and asked MD I what the expectation is for temperature in the spa tub. MD I reported that temperatures should not exceed 110 degrees F. MD I explained process and temps were in normal range. Water temperature is high when water comes out, and water cools at the exchange. Surveyor asked if logs of temperature checks are kept and if Surveyor can review the logs of the boiler and water exchange/tank logs. MD I reported that no logs for tracking of the temperatures in the boiler or water holding tanks are kept, but the spa tub temperatures are checked once a month. On [DATE] at 4:47 PM, Surveyor interviewed Licensed Practical Nurse (LPN) L and asked if LPN L could explain the events on [DATE] with R1 in the spa room. LPN L reported working on another wing when all the chaos occurred. LPN L rushed into spa room on 100-wing and saw everyone standing around R1 in the tub. There was no vital machine in the spa room and staff were trying to drain the water out of the tub. Surveyor asked LPN L if staff were performing CPR on R1. LPN L reported to Surveyor that the staff were not. LPN L stated, They were all just standing there, really doing nothing, waiting for the water to drain. Surveyor asked LPN L to describe R1's presentation when LPN L walked into the spa room. As the water was draining, LPN L could see R1 was so red. R1's skin was so red. R1 was gurgling and had very shallow breaths. R1was laid back with his head hanging back and eyes closed. LPN L reported not remembering much else at this time.On [DATE] at 5:20 PM, Surveyor interviewed CNA Q and asked for a walk through of the events on [DATE] with R1 in the spa room. CNA Q reported going into the spa room around 9:15 PM with RN J. CNA Q observed crash cart in spa room sitting in the corner, R1 was unresponsive, but CNA Q thought R1 was sleeping and heard R1 making gurgling sounds. CNA Q started poking R1 and calling R1's name. R1 did not respond to CNA Q. RN J asked CNA Q to stay with R1 while RN J ran to get help. CNA Q reported R1 was leaning way back in the spa tub's chair, left arm hanging over the tub limp, and the water was still running. CNA Q reported the water was extremely high. CNA Q reported CNA Q had to turn the water off. Surveyor asked CNA Q if R1 had safety belt on in the spa tub. CNA Q reported R1 did not have the safety belt on. Surveyor asked about facility providing education on the spa tub usage and any education after the incident on [DATE]. CNA Q reported the facility is pumping education out now and CNA Q received several texts earlier today after lunchtime to acknowledge the education regarding the spa room and not allowing more than 30 minutes.On [DATE] at 5:30 PM, Surveyor interviewed LPN M and asked LPN M to explain the events on [DATE] with R1 in the spa room. LPN M reported being R1's nurse the evening of [DATE]. LPN M reported that in the evening CNAs reported they would be giving R1 a spa bath before bedtime. LPN M did not realize R1 was in the spa tub until long after 7 PM. LPN M reported after 9:00 PM, she received a report from CNA D that R1 was taking too long in the spa room and that R1 was still in the spa tub. LPN M immediately went back to the nurse's station desk to send a communication text to the provider for timed limit on R1's spa bath as LPN M felt it was too long being in the spa tub. LPN M reported that R1 was an assist of 1 and should have never been left alone especially because R1 presented with slight cognition issues from having COVID and then acquired a Urinary Tract Infection (UTI) a couple of weeks ago. LPN M reported when LPN M went into the spa room LPN M observed R1 was pale, leaning backwards, with left arm over the tub. Catheter bag was floating in the water in the tub with creamy colored urine displayed in the catheter bag. LPN M observed the room was steamy. LPN M stuck her hand in the water, which was hot but not like jacuzzi hot. Respirations were shallow and LPN M could see perspiration on R1's forehead. LPN M reported that none of the staff could unplug the spa tub. CNA G came in and took his long arms and unplugged the tub. When CNA G reached in to pull the plug in the tub, CNA G also pulled out a washcloth that was plugging the drain as well. LPN M reported a short while later EMS arrived, and it took 4 of the guys to get R1 out of the tub. EMS used Narcan on R1 which was unsuccessful. EMS reported to nurses that R1's temperature was 106 F. Surveyor asked if LPN M has received any education regarding the incident from [DATE]. LPN M reported the only education was texted recently for us to acknowledge that we received it pertaining to not leaving resident alone in the spa tub.On [DATE] at 9:03 AM, Surveyor interviewed RN J who was the RN who found R1 unresponsive in the spa room. RN J received a report from LPN M who stated, R1 is refusing to get out of the bath, and it's been since 7:00 pm when R1 went in. RN J asked LPN M why LPN M hasn't gone in yet, and LPN M reported to RN J that LPN M wants to get an order from the doctor for time allotted during spa tub time first. RN J stated RN J went into spa room around 9:15 PM to check crash cart and to ask R1 to please get out of spa bath. RN J stated RN J took CNA Q in the spa room as well. RN J stated RN J could see something was wrong as R1 had his head lying back, shallow breathing, gurgling, and he was not submerged but water was pretty high. RN J stated she gave R1 a hard sternal rub, checked pulse which was 128, and CNA Q was trying to shake his left arm to wake him up. R1 was unresponsive. RN J stated RN J needed to check to see if he was a full code, so RN J asked CNA Q to stay in spa room with R1. Another nurse called 911. RN J stated they could not get the water to drain and then noticed washcloths at the bottom of the tub covering the drain. CNA G came in and pulled the washcloths out and stated, The water was very hot. Shortly after that, EMS arrived, and it took 4 guys to get R1 out of tub. Oxygen was then placed on R1 when EMS arrived. On [DATE] at 9:27 AM, Surveyor interviewed CNA G and asked what involvement CNA G had with R1's incident on [DATE]. CNA G reported he was called to the 100-wing spa. Staff asked CNA G to unplug the spa tub. CNA G reported he stuck his hand and arm in the spa bath and the water was hot. CNA G stated, It was too warm and unpleasant to submerge my hand in, but I needed to get the drain unplugged. I pulled out 4 washcloths. Surveyor asked CNA G if the drain was closed once the washcloths were pulled up. CNA G reported the drain was open and must have been slow to drain due to the washcloths plugging it. CNA G stated R1 was not responsive, gurgling like secretions were in his airway, and there were 5 different staff members in the spa room at that time standing and watching R1 until CNA G unplugged the drain. Surveyor asked CNA G what R1's skin looked like. CNA G stated, Well I am not good with colors, but kind of like red tinged from chest level down. Surveyor asked if CNA G has ever been trained on the spa usage or how to use the spa controls. CNA G reported he did not receive

Based on observation and interview the facility did not provide adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member, or to a centralized staff work area, for 1 resident (R1) out of 6 sampled residents. This had the potential to affect all 6 residents. * R1 did not have access to a call light while R1 was left in spa room unsupervised. Findings include: On 10/02/25 at 10:29 AM, Surveyor observed spa room down 400-wing. Surveyor did not observe a call light in the spa tub room. Surveyor did not observe a call light cord long enough to reach to the spa tub room from the shower room. On 10/02/25 at 10:36 AM, Surveyor observed spa room down 100-wing. Surveyor did not observe a call light in the spa tub room. Surveyor did not observe a call light cord long enough to reach to the spa tub room from the shower room. On 10/02/25 at 3:14 PM, Surveyor interviewed Director of Nursing (DON) B and asked DON B's expectation for call lights in the spa room and staff utilizing the call light. DON B reported that if staff leave a resident in the spa room, DON B would expect that a call light is in reach. Surveyor asked DON B if there was a reachable call light in the spa room. DON B reported that DON B knows there is one near the shower area. On 10/02/25 at 5:15 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A if it was facility practice to leave R1 alone in the spa tub. NHA A stated R1 is his own person and can have privacy in the tub. Surveyor asked if NHA A knew there was no call light in the spa tub room. NHA A reported that NHA A was unaware there was no call light in spa room and there are call lights at the vanity and shower in each spa room. NHA A reported to Surveyor that R1's preferences are to be left alone while taking a spa bath. Surveyor asked if R1 was assessed to safely bathe on own in spa room. NHA A reported that R1's preference had not been care planned, but everyone knew that he liked his privacy in spa room. Surveyor asked what the expectation is for staff leaving R1 without a call light in reach. NHA A reported that NHA A didn't realize there was not a call light in reach. On 10/07/25 at 1:23 PM, Surveyor interviewed DON B and NHA A and asked if DON B and NHA A could walk with Surveyor to the 100-wing spa room. Surveyor asked NHA A to show Surveyor where call lights were in the spa room. NHA A grabbed a call light to show Surveyor in the entrance of the spa room. There were 3 call lights located near the vanity, again another about 5 feet and then another near the shower. Surveyor asked if the string to the call lights could reach into the other room where the spa tub is located. NHA A and DON B reported that call light does not reach to the spa tub. Surveyor asked if there was a call light in the spa room. NHA A reported to Surveyor there was not a call light in the spa room. Surveyor asked why there was not a call light accessible to R1 at the time of the event on 09/29/25. NHA A stated, I don't know. I didn't build the building.

Based on interview and record review, the facility did not immediately report to the resident's representative when a resident was found unresponsive in spa tub and was transferred via Emergency Medical Services (EMS) to the Emergency Department (ED). This occurred for 1 of 1 resident (R) reviewed, (R1).Findings include: R1 was admitted to the facility on [DATE] with diagnoses including, in part, chronic obstructive pulmonary disease, left bundle branch block, bipolar disorder with moderate depression, COVID-19 respiratory disease, urinary tract infection, hypertensive chronic kidney disease stage 1-4, epigastric pain chronic, flaccid neuropathic bladder, anxiety, hyperlipidemia, insomnia, peptic ulcer, benign prostatic hyperplasia, right artificial hip and knee joint. R1's Minimum Data Set (MDS) assessment, dated 09/05/25, identified on admission that R1 had a Brief Interview for Mental Status (BIMS) score of 14. This indicated R1 had intact cognition. The MDS assessment also identified R1 required partial/moderate assist with bathing/showering self. R1 was partial/moderate assist with bathing/shower transfers.R1's progress notes reviewed and stated, -On 09/29/2025 at 9:47 PM, Resident in spa room, resident not verbally responding to RN, Resident did not respond to sternal rub. Resident was breathing, had a strong pulse. EMS was called and proceeded to provide care. Resident sent to the ED. Report given to ED nurse. Resident provided with bed hold and transfer appeal rights.-On 09/30/2025 at 3:09 AM, resident is being transferred to [NAME]. On 10/02/25 at 7:04 PM, Surveyor interviewed Family Member (FM) T and asked if FM T had any updates pertaining to R1's disposition in the hospital and if FM T could provide any updates about R1's condition. FM T stated to Surveyor, I do not know what you are talking about. What happened to my brother? Why am I now just hearing my brother is in the hospital. What hospital? When? How long will he be there? Surveyor asked FM T if facility had contacted FM T about the incident with R1 on 09/29/25. FM T reported to Surveyor that FM T does not know what is going on and is very overwhelmed at this moment. Surveyor suggested that FM T call the facility for an update and to clarify what had occurred. FM T thanked Surveyor for Surveyor's time and hung up the phone to call facility. On 10/03/25 at 8:36 AM, Surveyor spoke with R1's emergency contact FM T again and asked if FM T received information about R1's condition and disposition. FM T reported that FM T has not heard from the facility yet. FM T reported that FM T was very upset as FM T called the facility last night on 10/02/25 and staff told FM T that he would have to wait until administration is in the building and would not divulge any information. FM T reported to Surveyor that on 10/03/25 at around 8:00 AM, FM T called facility and again was told FM T would have to wait until administration was in the building. FM T reported that Nursing Home Administrator (NHA) A was rude and only stated to FM T that an incident happened where R1 was left unsupervised and became unresponsive and sent via EMS to the hospital. FM T reported to Surveyor that NHA A gave FM T the hospital name and asked FM T to call for more details. FM T stated to Surveyor, I am very upset that this has happened. What was my brother doing alone in the tub for that long? Why was I not given more information about this incident? Surveyor suggested to FM T that FM T should contact hospital to check on R1. On 10/06/25 at 9:03 AM, Surveyor interviewed Registered Nurse (RN) J who was the RN who found R1 in R1's condition in the spa room. Surveyor asked if RN J notified physician on call or R1's emergency contact. RN J reported that RN J did not because in a situation like this R1 is his own person and that we usually just ask the resident, but since R1 was unresponsive that RN J usually just makes that nurse judgement on her own. RN J reported that RN J contacted Emergency Department (ED) Physician S in the ED to report the incident but did not call R1's emergency contact, FM T. On 10/07/25 at 9:45 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked why R1's emergency contact, FM T, was not contacted about the incident on 09/29/25. NHA A reported that NHA A spoke with R1's emergency contact, FM T. Surveyor asked NHA A when NHA A spoke with R1's emergency contact FM T. NHA A reported that NHA A spoke with FM T on 10/03/25 and answered all of FM T's questions. Surveyor asked if NHA A notified FM T that R1 had an incident on 09/29/25 and was transferred to hospital after the incident. NHA A reported that NHA A contacted R1's POA on 10/02/25 which was activated on 10/02/25 in hospital. Surveyor asked NHA A if R1's emergency representative, FM T, was contacted the same day of R1's incident on 09/29/25 at that time. NHA A reported to Surveyor that NHA A does not know if anyone else contacted FM T.

Based on the interview and record review, the facility did not report 1 of 1 (R1) potential misconduct incidents to the State's Office of Caregiver Quality (OCQ) via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incident.Findings include: Facility policy titled, Abuse Prevention, dated reviewed on November 23, 2016, states in part: .Neglect Definition-Means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.*Facility will immediately report all alleged violations involving mistreatment, neglect, of abuse, including injuries of unknown source to the facility administration and to the Division of Quality Assurance. CMS defines immediately to be as soon as possible but not to exceed 24 hours after discovery of the incident. R1 was admitted to the facility on [DATE] with diagnoses including, in part, chronic obstructive pulmonary disease, left bundle branch block, bipolar disorder with moderate depression, COVID-19 respiratory disease, urinary tract infection, hypertensive chronic kidney disease stage 1-4, epigastric pain chronic, flaccid neuropathic bladder, anxiety, hyperlipidemia, insomnia, peptic ulcer, benign prostatic hyperplasia, right artificial hip and knee joint. R1's Minimum Data Set (MDS) assessment, dated 09/05/25, identified on admission that R1 had a Brief Interview for Mental Status (BIMS) score of 14. This indicated R1 had intact cognition. The MDS assessment also identified R1 required partial/moderate assist with bathing/showering self. R1 was partial/moderate assist with bathing/shower transfers. On 10/02/25 at 2:25 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked for any type of incidents that require an investigation that may have been reported or were in the process of being reported. NHA A stated to Surveyor, If it is reportable then it would be obviously reportable. Surveyor asked NHA A again if there were any incidents that NHA A is working on that have not been reported. NHA A reported that any of those incidents would be considered in our Quality Assurance QI department for PIPs and that it is confidential. On 10/02/25 at 3:14 PM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B had any other incidents or investigations that DON B is working on. DON B explained DON B's process for managing incidents like falls, med errors, etc. is that they are kept in a binder, reviewed at daily meetings, and then new interventions are implemented. DON B reported to Surveyor that NHA A and Assistant Director of Nursing (ADON) C have been working on an incident with R1 and the spa room from 09/29/25 where R1 was left unsupervised and found unresponsive. DON B and Surveyor then went to NHA A's office for investigation documents. On 10/02/25 at 3:17 PM, Surveyor entered NHA A's office. In attendance were NHA A, DON B, and regional resource staff. Surveyor asked NHA A why R1's incident was not reported to OCQ. NHA A reported to Surveyor that through investigation NHA A found there was no willful intent and did not report the incident pertaining to R1 being left in the spa room unsupervised and becoming unresponsive requiring EMS transport to a higher level of care. NHA A stated to Surveyor, I did not feel it was necessary to report the incident, therefore I did not.

Based on record review and interview, the facility did not conduct a Preadmission Screening and Resident Review (PASRR) Level II screen for R7, who has a serious mental disorder and is taking psychotropic medication to treat symptoms of major mental disorder to ensure he received care and services in the most integrated setting appropriate to his needs. The facility practice affected 1 of 2 residents reviewed (R7). This is evidenced by: Surveyor requested and reviewed the policy titled Forward Health Update, Your First Source of Forward Health Policy and Program dated November 2023. The policy in part read: PASRR Level II Referrals: ~As part of the PASRR Level I screen process in the portal, if required, the completed Level I screen will be forwarded on to Wisconsin's PASRR onto Wisconsin's PASRR Level II screen. ~The Level II screen is in place to determine if a person has a .serious mental illness as defined by federal PASRR regulations. Responses completed during the Level I screening process will determine if a Level II screen should be completed. ~If the Level I screen requires a Level II screen referral any relevant documentation must be submitted . ~Once the Level II contractor completes the Level II screen, the results will be accessible through the portal . R5 was admitted [DATE] with diagnoses that included, bipolar disease: current episode-depressed moderate, unspecified mood disorder and anxiety disorder. Surveyor reviewed R7's record and noted his physician orders included Trazadone and Fluoxetine (Psychotropic) medication since his admission on 11/09/23. Surveyor reviewed R5's record and located a Level 1 Preadmission Screening and Resident Review (PASARR) screening dated 11/09/23 noting R7 has a major mental disorder and has taken psychotropic medications to treat symptoms or behaviors of a major mental disorder under a short-term hospital discharge exemption-30-day maximum. Surveyor reviewed R7's record and could not locate a Level II PASRR screening. On 8/07/24 at 9:03 AM, Surveyor interviewed Social Services Director (SSD) C who is responsible in part for the facility's PASRR screening process. SSD C explained R7 was initially admitted for short-term rehabilitation from the hospital under a 30-day exemption. A Level 1 PASRR screening was needed at admission due to R7 having a serious mental health condition and on medication of Trazadone and Prozac (Fluoxetine). A request was submitted for a 30-day exemption on admission 11/09/23. The request was sent to human services. The facility did not receive the exemption back. Normally the facility receives the requests back in about a week and if not received a call would be placed. Normal process would be to request a Level 2 PASRR after the 30-day exemption ended. The facility did not receive the Level I exemption back thus a Level 2 was missed. A Level II should have been completed. The Level 2 would need to be submitted once the 30 day exemption ended. SSD C indicated R7 still needs an exemption and Level 2 completed and it will be done today. SSD C stated the purpose of the PASRR screenings are to ensure residents with such diagnosis and on prescription medications are in the most appropriate setting and do not need additional services in a different setting.

Based on observation, interview and record review, the facility did not develop and implement a comprehensive individualized care plan to meet the needs of 2 of 18 residents (R) R29 and R8. This is evidenced by: According to the Resident Assessment Instrument, The comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. Example 1 R29 was admitted to the facility on [DATE] with diagnosis of neurocognitive disorder with Lewy bodies-with behavior disturbance and dementia and is on palliative care. R29's most recent Minimum Data Set (MDS) is an annual assessment with a date of 07/20/24 indicating R29 requires partial to moderate assistance for personal hygiene, dependent for putting on footwear, dependent for dressing lower body, substantial to maximum assist to roll left to right, and dependent going from sitting to lying. R29 has short-term and long-term memory impairment and has severely impaired daily decision-making abilities. R29's Braden Scales (assessment for predicting pressure sore risk) dated 01/18/24 indicated a score of 15 (at risk) and on 04/19/24 indicated a score of 14 (moderate risk). R29's care plan dated 05/03/19 with a goal target date of 10/23/24 for resident to remain free from complications related to deep tissue injury (DTI) on left (L) heel. R29's physician orders dated 04/09/24 state to wear blue boots to bilateral heels at all times. R29's nurses notes state in part, Resident has an DTI area 3.5 cm L x 2 cm W. that has an area that is scabbed 70% w/brown scab, nonviable tissues 30%, cream colored to left heel. No drainage noted. No odor noted. Betadine with foam dressing change every 3 days and PRN. Blue boots to bilateral feet. R29's DTI resolved on 05/29/24. On 08/07/24 at 9:54 AM, Surveyor observed Certified Nursing Assisant (CNA) E and CNA D assist R29 to utilize the bedpan and morning cares. During observation, Surveyor did not see either CNA place or attempt to place blue heel boots to offload bilateral lower extremities per care plan or offer an alternate intervention to float heels. On 08/07/24 at 1:03 PM, Surveyor observed R29 lying on back with heels directly on mattress. On 08/07/24 at 1:07 PM, Surveyor interviewed CNA D, who stated that R29 no longer has issues with heels, and is unaware if resident is supposed to wear the blue boots anymore. On 08/07/24 at 2:11 PM, Surveyor interviewed Director of Nursing (DON) B regarding the observation of R29 not wearing blue heel boots per care plan. DON B stated probably because R29 refuses the boots and is care planned of frequently refusing interventions. Surveyor shared observation of cares this AM by staff and no attempt of placing blue heel boots or offering an alternate approach to float heels. R29 was not given the opportunity to accept or refuse the blue heel boots. DON B provided Surveyor a copy of the care plan which indicated the approach of blue boots to offload to bilateral lower extremities, at all times, if refuses the boots free float heels as tolerated. DON B confirmed the care plan intervention was not implemented for R29. 40590 Example 2 R8 was admitted to the facility on [DATE] and has a diagnosis of hypertensive heart and chronic kidney disease with heart failure. R8 is on hospice care. According to nursing documentation, a new sore in middle of coccyx was discovered on 07/24/24. Surveyor reviewed the medical record and could not locate a comprehensive care plan for R8's Pressure Injury (PI). On 8/7/24 at approximately 11:00 a.m., Surveyor interviewed DON B, asking about the PI care plan. On 08/07/24 at 11:30 AM, Surveyor received a care plan from DON B for R8's facility acquired pressure injury with problem start date of 08/07/24. This was developed after Surveyor asked for the information on 8/7/24.

Based on observation, interview and record review, the facility did not ensure treatment and care were provided in accordance with professional standards of practice for 1 of 3 sampled residents (R)228. The facility did not give instruction on the care plan for staff on the proper use of R228's C-collar (cervical neck brace) or Cervical Thoracic Orthosis (CTO) body brace, nor did staff recognize when the brace was applied incorrectly, and not applied as ordered by the physician. This resulted in pain and an emergency room visit for evaluation for R228. This is evidenced by: R228 was admitted to the facility on [DATE] at 3:25 p.m., and has diagnoses that include, in part, head injury, neck fracture in 3 areas, fractures in 2 areas of the upper back, multiple rib fractures and collar bone fracture following a motor vehicle accident. Surveyor reviewed doctor's order, dated 08/24/23, that indicated R228 needs to wear C-collar at all times and CTO brace when (sitting up) greater than 45 degrees, sitting upright or out of bed. Baseline care plan, dated 08/24/23, states to wear C-collar at all times and CTO when out of bed. The care plan did not provide instructions for staff to properly apply and remove C-collar or CTO body brace and/or report concerns or refusals to the nurse prior to assisting R228. Manufacturer's instructions stated that the patient's chin should be flush with the end of the collar chin piece for proper positioning of the C-collar. On 08/28/23 at 10:27 AM, Surveyor observed R228 lying in bed with C-collar on with chin through the bottom opening of the chin rest instead of on top. R228 stated a girl brought him to the bathroom at 2:00 a.m. without the proper neck brace on and thought R228's neck rebroke. R228 rated pain 14-16 on a 0-10 scale with 10 being the highest level of pain. R228 was whispering and stated that it is painful to talk, he cannot swallow and cannot take it. Surveyor immediately notified staff. On 08/28/23 at 10:36 AM, CNA C entered R228's room and asked if R228 wants to go to the emergency room (ER). CNA C did not recognize that the C-collar was on incorrectly or notify the nurse of the incorrectly placed brace. When Surveyor asked if she received anything in report, CNA C stated that RN L left note stating, 111 [referring to room number] wants to remind staff his long neck brace must be on when he gets up Thanks, [RN L]. On 08/28/23 at 10:43 AM, Surveyor observed RN E enter R228's room. RN E did not notice that the C-collar was on incorrectly. Surveyor interviewed RN E who reported she offered to send R228 to ER this morning around 7:00 AM-7:30 AM due to increased pain in R228's neck from the C-collar not being applied when R228 was sitting up and R228 requested to wait and see if the pain went away. On 08/28/23 at 10:52 AM, RN E called for emergency services to transport R228 to the hospital. On 08/28/23 at 11:05 AM, First Responder (FR) F and FR G arrived. RN E reported to FR F and FR G that someone brought R228 to the bathroom without his C-collar in place and R228 sat like that for 20 minutes. FR's stated that the C-collar was not applied correctly. FRs corrected it and moved it so chin was resting on chin rest and not through bottom opening on collar. R228 was then transported to the hospital, received scans and it was verified that there were no new fractures and R228 was then transported back to the facility the same day. On 08/30/23 at 8:29 AM, Surveyor interviewed Director of Nursing (DON) B. Surveyor asked, What is the facility's practice when residents are admitted with specialized devices? DON B replied, Follow the doctor order for using the device, seek guidance from therapy to ensure we are using it correctly, add to care plan to communicate with staff, provide skin checks underneath the splint and this is noted in the nursing orders. Surveyor asked, How do you know that the staff can properly apply and remove specialized devices? DON B replied, It is a part of our routine training and the nurse on the unit should be checking for appropriate placement. Surveyor then asked DON B if she could show Surveyor in the care plan for R228 where the instructions are for staff to follow on how to apply and remove the C-collar and CTO for R228. DON B pulled up the care plan that indicated that R228 needs the C-collar on at all times and the CTO when out of bed. DON B added that there are instructions on the cork board in his room. Note: Instructions were not in R228's room until after Surveyor informed the facility of the deficient practice on 08/28/23. Facility staff did not have proper training or instruction on how and when to apply R228's braces to ensure appropriate care was given when admitted to the facility with a cervical injury. On 08/30/23 at 8:50 AM, Therapy Director (TD) H was interviewed and asked, In regard to [R228], did the therapy department educate any staff on how to apply and remove [R228's] C-collar and CTO prior to 08/28/23? TD H stated, I will need to check and see. Surveyor asked, How does therapy educate staff on the process? TD H reported, There is a picture in his room for staff, therapists educate the patient and staff on a daily basis. Surveyor asked, How are other shift staff educated when therapy staff are not available? TD H said, It is up to the nursing department to communicate to rest of the staff.

Based on observation, record review and interview the facility did not ensure appropriate care and services were provided to prevent urinary tract infection (UTI) for 1 of 1 resident reviewed with an indwelling catheter (R38). R38 did not have a physician order or care plan with specific approaches for care of the indwelling catheter. This is evidenced by: Surveyor requested and reviewed the facility policy titled Catheter Care, Urinary, which was not dated. The policy in part read: Purpose: The purpose of this procedure is to prevent infection of the resident's urinary tract. General Guidelines: ~Determine if changes in daily urinary catheter procedures have been made (e.g. review of care plan .physician orders, ect.). ~Observe the resident for signs and symptoms of urinary tract infection and urinary retention . On 08/28/23 at 10:22 AM, Surveyor spoke with R38 regarding her catheter. R38 indicated staff take care of her catheter by emptying her urine. Surveyor observed a urinary catheter hanging on R38's lower bed rail. Surveyor reviewed R38's Admission Minimum Data Set (MDS), dated [DATE], which notes resident occasionally is incontinent of urine. R38's Significant Change in Status MDS dated [DATE] notes resident has an indwelling catheter. Surveyor reviewed R38's physician orders and noted there were no orders present regarding R38's indwelling catheter or for care of the catheter. The orders strictly included: 6/19/23: Record foley output each shift. Surveyor reviewed R38's Treatment Administration Record, which shows no nurse monitoring of R38's catheter. Surveyor reviewed R38's care plan and noted the following: Care plan: Problem: SELF CARE DEFICIT R/T (related to) decline in status, readmitted under hospice care, Mobility deficits, endurance concerns, weakness. Start Date 05/24/2023, Last Reviewed/Revised: 06/27/2023 Approach: Toileting: Requires assistance, has catheter in place d/t (due to) retention; incontinent of bowel, assist with peri-care and brief change Start Date: 06/27/2023 Although R38's care plan states she has a catheter in place, it does not have approaches to direct staff in the care of the catheter. On 08/30/23 at 7:14 AM, Surveyor requested R38's physician order and care plan for care of resident catheter. On 08/30/23 at 9:46 AM, Surveyor interviewed Director of Nursing (DON) B about R38's hospital records from discharge on 6/14/23. DON B indicates the hospital records show a Foley catheter was placed while R38 was in the hospital. The order was not clarified and transcribed from the hospital records. Nursing should have transcribed/clarified the physician order related to specific catheter and care of the catheter. The order should be specific to include Foley size, balloon size, orders for changes; if different than facility protocol and catheter secure change. An order would have triggered nurse monitoring via R38's treatment records. DON B expressed the facility would expect nursing staff to monitor urine output, patency of the catheter, any discomfort related to the catheter and any signs or symptoms of a urinary tract infection. A physician order would have triggered the nurse monitoring via the treatment records. There is no evidence nursing staff were monitoring R38's catheter. DON B also expressed she would expect R38 have a care plan specific to care of R38's catheter. There was no care plan in place with specifics for care of R38's catheter. DON B provided Surveyor with R38's Physician Plan of Care (PPOC) from her hospital discharge on 6/14/23. The PPOC notes Genitourinary (check those ordered) Foley. There PPOC did not include Foley size, balloon size or orders for changes. There were no specific care instructions provided by R38's physician.

Based on record review and interview, the facility did not comprehensively assess trauma or develop a trauma-informed care plan for 1 of 1 resident (R) 1, with diagnosis of post-traumatic stress disorder (PTSD) and history of trauma. R1 has a diagnosis of PTSD with her admission assessment identifying past trauma. The facility did not comprehensively assess R1's trauma or develop a trauma informed care plan. This is evidenced by: Surveyor requested and reviewed the facility policy titled Trauma Informed Care, which is not dated. The policy in part reads: Purpose: To guide staff in appropriate and compassionate care specific to individuals who have experienced trauma. General Guidelines: ~This facility supports a culture of emotional well-being and physical safety for staff, residents and visitors. ~Trauma-informed care is culturally sensitive and person-centered . Resident-Care Strategies ~As part of the comprehensive assessment, identify history of trauma or interpersonal violance when possible. Identifying past trauma or adverse experiences may involve record review or use of screening tools. ~The IDT (Inter-disciplinary team) will assess and care plan triggers related to trauma to promote a safe and supportive environment for the resident. The care plan will include directives for care related to past trauma experiences to prevent further traumatic response as indicated. On 8/28/23 at 12:24 PM, Surveyor spoke with R1 who indicated has issues with depression due to past trauma both childhood and adult. R1 expressed she sees a psychiatrist/counselor. R1 indicated she has a depressed mood at times and certain things set her off and cause her stress. R1 sometimes cries due to family issues. Surveyor reviewed R1's record and noted diagnoses which included depression and PTSD on her admission Minimum Data Set (MDS) dated [DATE] and most recent quarterly MDS dated [DATE]. R1's quarterly MDS on 7/13/23 compared to her admission MDS dated [DATE] shows depressive mood symptoms decreased. R1's physician orders included: ~ 11/21/22: Paroxetine 40 mg QD ~11/21/22: Trazadone 100 mg QD Medications ordered for targeted behaviors of crying, sadness and anxiousness. Resident Psychosocial Well Being Assessment done on admission 11/11/22 notes the following: Have you ever experienced, witnessed or suffered trauma related to a traumatic event (i.e. assault, abuse ect.)? Yes If you experienced a traumatic event, provide details of the event and timeframe of when the trauma occurred as you are willing/able: Physically abused by husband who was an alcohol. What are the triggers that remind you of the event (e.g. loud noises, confined spaces, sirens ect.)? not completed. How do you react when remind of the event (s)? Not completed. When you are reacting to the past event (s) what helps you find comfort? talk What type of help/services have you received to address your response to the event (s)? Medication: checked If known history proceed to care plan. Care plan: Problem: Resident is displaying symptoms of mild depression or has the potential for impaired coping/depression related to boyfriend's passing. Start Date: 04/25/2023 Last Reviewed/Revised 07/14/2023 Goal(s): Resident will be able to talk about his/her illness and establish end of life care plan with resident and family, identifying and developing realistic goals. Target Date: 10/14/2023 (Short Term Goal) Approach: Make referrals as indicated. Start Date 4/25/2023 Approach: Administer medications as ordered, monitor for side effects and effectiveness. Start Date 4/25/2023 Approach: Encourage and assist the resident in maintaining activities that promote comfort/joy. Start Date 4/25/2023 Approach: Maintain a calm environment, convey an attitude of acceptance towards the resident. Start Date 4/25/2023 Approach: Offer support and socialization. Start Date 4/25/2023 Approach: Assist resident and family in discussion overall condition/prognosis with clinical staff, including physician. Start Date 4/25/2023 Approach: Allow resident to verbalize feelings. Talk privately with Social worker or Clergyman or Psychotherapist if resident wishes. Start Date 4/25/2023 Although R1's care plan addresses depressive symptoms, Surveyor could not locate care planned approaches for PTSD, accounting of resident experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization. On 8/29/23 at 9:37 AM, Surveyor interviewed Director of Nursing (DON) B about R1's incomplete psychosocial well being assessment and care plan. DON B expressed she would expect a trauma informed assessment be thoroughly completed when PTSD is identified with care planning looking at triggers and what makes the person comfortable. R1's assessment was not complete, and her care plan did not include trauma-informed care.

Based on observation, interview and record review, the facility did not ensure that nursing staff had the specific competencies and skill set necessary to care for 1 of 1 resident (R)228 with specialized needs. Staff did not have the competency and training to appropriately don and doff a C-collar (cervical neck brace) and a Cervical Thoracic Orthosis (CTO) (upper body brace) for R228's care. Findings include: R228 was admitted to the facility on [DATE] at 3:25 p.m., and has diagnoses that include, in part, head injury, neck fracture in 3 areas, fractures in 2 areas of the upper back, multiple rib fractures and collar bone fracture following a motor vehicle accident. Surveyor reviewed doctor's order, dated 08/24/23, that indicated R228 needs to wear Aspen collar (C-collar) at all times and CTO brace when (sitting up) greater than 45 degrees, sitting upright or out of bed. Care plan dated 08/24/23 states to wear Aspen collar (C-collar) at all times and CTO when out of bed. On 08/28/23 at 10:36 AM, Surveyor observed Certified Nursing Assistant (CNA) C checking on R228 and did not recognize the C-collar was on incorrectly. CNA C stated that R228 was admitted 4 days ago, and it was her first day caring for R228. Surveyor asked CNA C and CNA D who were assisting R228 that day if they had prior experience or received any training on the C-collar and CTO which they stated they did not. On 08/28/23 at 10:43 AM, Surveyor interviewed Registered Nurse (RN) E. RN E entered R228's room and did not recognize that the C-collar was on incorrectly. Surveyor asked RN E if she received training on the C-collar and CTO and she said she did not. On 08/28/23 at 11:05 AM, First Responder (FR) F and FR G arrived. FRs stated that the C-collar was not applied correctly. On 08/30/23 at 8:29 AM, Surveyor interviewed Director of Nursing (DON) B and was asked, What is the facility's practice when residents are admitted with specialized devices? DON B replied, Follow the doctor order for using the device, seek guidance from therapy to ensure we are using it correctly, add to care plan to communicate with staff, provide skin checks underneath the splint and this is noted in the nursing orders. Surveyor asked, How do you ensure staff have the competency to properly don and doff specialized devices? DON B replied, It is a part of our routine training, the nurse on the unit should be checking for appropriate placement. Surveyor asked, Is there documentation that this training occurred? DON B replied, It goes back to standards of practice, and they do not require staff to sign off that they were trained on the specialized devices. On 08/30/23 at 8:50 AM, Therapy Director (TD) H was interviewed and asked, In regard to [R228], did the therapy department educate any staff on how to don and doff [R228's] C-collar and CTO prior to 08/28/23? TD H stated, I will need to check and see. Surveyor asked, How does therapy educate staff on the process to ensure competency on applying the splints? TD H reported, There is a picture in his room for staff, therapists educate the patient and staff on a daily basis. Surveyor asked, How are other shift staff educated when therapy staff are not available? TD H said, It is up to the nursing department to communicate to rest of the staff. Facility did not provide any evidence that specialized training was completed to ensure competency on the use of a C-collar or CTO.

Based on observations, interviews and record reviews, the facility did not ensure a medication administration rate of less than 5%. During the Medication Administration Task, there were 3 errors out of 36 opportunities observed, yielding a medication administration rate of 8.33%. Resident (R) 20 self administers her inhalers upon directions by staff. Registered Nurse (RN) E handed R20 the Corticosteroid inhaler to administer, before the bronchodilator inhaler. Following the Corticosteroid inhaler administration, RN E did not encourage or offer R20 to rinse her mouth. R45 was given fast-acting insulin (Humalog) at 7:32 AM and did not eat a meal until 8:28 AM. This was 56 minutes after the administration of a fast-acting insulin. This is evidenced by: Drugs. com states for Symbicort, .To reduce the chance of developing a yeast infection in your mouth, rinse with water (but do not swallow) after using this medicine . Drugs.com also states Symbicort contains a combination of budesonide and formoterol. Budesonide is a corticosteroid that reduces inflammation in the body. Formoterol is a long-acting bronchodilator that relaxes muscles in the airways to improve breathing. Albuterol is a bronchodilator. Bronchodilators open up the airway and relax the smooth muscles enabling an increase in air flow to the lungs and should be given prior to a combination or corticosteroid medication in order for the lung passageways to open fully to accept the second medication more thoroughly. Humalog.com states .Humalog starts acting fast. Inject Humalog within 15 minutes before or right after you eat a meal . Examples 1 On 8/29/23 at 7:40 AM, RN E and Surveyor entered R20's room with the morning medications. Included were Albuterol/ipatropium 2.5/3 milliliter nebulizer (bronchodilator) and Symbicort (budesonide-formoterol) inhaler (80-4.5 micrograms). RN E explained that R20 self administers the inhalers with nursing instructions. RN E then proceeded to hand R20 the Symbicort inhaler, in which R20 self administered two puffs. Immediately following the inhalation of Symbicort, RN E handed R20 the Albuterol/ipatropium hand-held nebulizer, which R20 also self-administered. In this observation, there were two errors: R20 should have been instructed to first take the Albuterol/ipatropium nebulizer to open up the airways so that the Symbicort would have been distributed properly throughout the lung fields; and once the Symbicort was administered, RN E did not encourage or instruct R20 to rinse her mouth and spit. Without doing so, R20 poses a risk for the development of an oral yeast infection. In reviewing R20's physician orders, Surveyor noted under budesonide-formoterol's special instructions, Rinse mouth and spit after use .Wait 5 minutes before administering another inhaler. RN E was not available for interview following this administration. On 8/30/23 at 8:56 AM, Surveyor interviewed Director of Nursing (DON) B regarding the expectation of nursing when administering two different inhalant medications. DON B stated, They (nursing) should give the bronchodilator first to open everything up so that when the corticosteroid is given it can work effectively. Example 2 On 8/30/23, Surveyor observed RN K administer medications to R45. RN K administered Humalog (Lispro), 10 units at 7:32 AM. There was no substantial snack or juice given following this administration. R45 received the morning meal at 8:28 AM, or 56 minutes following the administration of the fast-acting insulin. At 8:42 AM, Surveyor interviewed RN K regarding knowledge of a fast-acting insulin. RN K stated that the resident should be eating within a half-hour of getting the insulin. Surveyor explained that Humalog is a fast-acting insulin that should be administered within 15 minutes before or right after a meal, and stated R45 received his meal 56 minutes after she administered the Humalog insulin. RN K then stated, Oh yeah, I should have waited to give it . I guess I was thinking that he has been high, I didn't consider the fast acting insulin. At 8:56 AM, Surveyor interviewed DON B regarding the expectation of administration of insulin in correlation with meal service. DON B stated fast-acting insulin should be given according to the doctor orders but generally within 30 minutes and the nurse should be checking the blood sugars in between. In reviewing the facility policy for insulin administration, the instructions to staff for rapid-acting insulin states the onset of action (how quickly the insulin reaches the bloodstream and begins to lower blood glucose) is 10-15 minutes.

Based on observations and interviews, the facility did not implement appropriate infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections. Staff did not perform hand hygiene when warranted or sanitize the durable medical equipment for 1 of 4 residents (R) R32 observed for cares. Certified Nursing Assistant (CNA) I did not perform hand hygiene when warranted when providing cares to R32. CNA I and CNA J did not sanitize mechanical lift before or after use for R32. This is evidenced by: Example 1 Surveyor requested and reviewed the facility policy titled Handwashing/Hand Hygiene. The policy in part reads, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy lists instances where employees must conduct hand hygiene. such as: Before and after direct resident contact. Before and after assisting a resident with personal care. Upon and after becoming in contact with a resident's intact skin. After contact with a resident's mucous membranes and body fluids or excretions. Before moving from a contaminated body site to a clean body site during resident care. After removing gloves. On 08/29/23 at 6:50 AM, Surveyor observed CNA I morning cares for R32. Care was provided by CNA I and transfer assistance was provided by CNA J. CNA I and CNA J washed hands, donned gloves, and gathered supplies. While R32 laid in bed, CNA I was observed completing the following tasks after donning gloves and without removing gloves or performing hand hygiene between tasks. CNA I applied skin prep to heels of feet and assisted in applying ace wraps and TED hose on legs, applied compression sleeve and glove to left arm and hand, removed soiled incontinent product and completed frontal incontinence care, wash and dried rectal area and placed clean incontinent product. CNA I then held hands of R32 to assist to sitting position, removed the nightgown from R32, and applied deodorant, clean shirt, and bra in preparation to transfer to wheelchair, placed mechanical lift sling around waist of R32, moved bedside table and moved lift into position in front of resident and operated the mechanical lift using remote control to transfer R32 to wheelchair, straightened clothing of R32 in preparation to go to breakfast. All tasks were completed with the contaminated gloves. CNA I removed gloves and took garbage out of room. Surveyor observed hand hygiene after CNA I walked out of room and disposed of garbage. On 08/29/23 at 11:02 AM, Surveyor interviewed CNA J regarding expectation of performing hand hygiene during cares that includes incontinence care. CNA J stated generally hand hygiene is conducted before and after cares. On 08/29/23 at 11:33 AM, Surveyor interviewed CNA I regarding the expectation of performing hand hygiene during cares that include incontinence care. CNA I stated hand hygiene is conducted before and after cares. On 08/29/23 at 4:42 PM, Surveyor interviewed Director of Nursing (DON) B about the observation. DON B stated the expectation would be to perform hand hygiene prior to starting cares and after incontinence care before touching other items. Example 2 Surveyor requested and reviewed the facility policy entitled Cleaning and Disinfection of Resident-Care items and Equipment, which is not dated, which states Reusable items are cleaned and disinfected between residents. On 08/29/23 at 11:02 AM, Surveyor observed CNA J place mechanical lift in hallway after transferring R32 for toileting care. Surveyor did not observe any sanitization of lift prior to or after use. On 08/29/23 at 11:02 AM, Surveyor interviewed CNA J about the process of sanitizing mechanical lift. CNA J stated sanitization of lift is conducted one time a shift, unless a resident is under precautions then sanitization is conducted before and after each use. On 08/29/23 at 11:33 AM, Surveyor interviewed CNA I about the process of sanitizing mechanical lift. CNA I stated that night shift sanitizes lifts and if a resident is under precautions then lift is sanitized before and after use. On 08/29/23 at 4:43 PM, Surveyor interviewed DON B about the observation and DON B stated the expectation would be to conduct sanitization of lifts after each use.

Based on observation, interview and record review, the facility did not assess resident risk for entrapment or attempt alternative methods prior to installing bed rails for 17 of 18 sampled residents (R33, R42, R51, R173, R12, R26, R65, R70, R6, R18, R28, R58, R60, R1, R5, R11, R36 and R41). All of these residents had postioning rails on their beds without an assessment completed to determine their risk for entrapment and without first attempting alternate methods prior to installing the rails on their beds. This is evidenced by: Surveyor requested and reviewed the facility policy titled Proper use of Rails dated 2001 with a revision on December 2007. The policy in part states: Purpose: The purposes of these guidelines are to ensure the safe use of rails as resident mobility aides and to prohibit use of rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: ~Side rails are considered a restraint when they are used to limit the residents freedom of movement ~Side rails are only permissible if they are used to treat a residents medical symptom or to assist with mobility and transfer of residents. ~An assessment will be made to determine the residents symptoms and reason for using the side rails . ~The use of the rails as assistive device will be addressed in the resident care plan. ~Consent for using restrictive devices will be obtained from the resident or legal representative ~If deemed a restrictive device: less restrictive interventions will be incorporated into care planning including: providing restorative care .providing a trapeze to increase bed mobility placing bed lower to the floor .surrounding bed with a soft mat equipping resident with a device that monitors attempts to rise .providing staff monitoring at night .furnishing visual and verbal reminders to use the call light ~The risks and benefits will be considered for each resident. An assessment will be completed to determine whether the rail is utilized as a restrictive or adaptive device based on each residents overall condition. ~Consent for side rails use will be obtained from the resident or legal representative, after presenting potential risks and benefits. ~When rail usage is appropriate the facility will assess the space between the mattress and side rails to reduce the risk for entrapment . Example 1 On 7/13/22 at 3:24 PM, Surveyor observed R33 lying in bed with bed rails on both sides of bed. The rails were in upright position and were approximately 1/4 length of R33's bed. R33's most recent quarterly Minimum Data Set (MDS) notes R33 requires extensive assistance of one staff for bed mobility and limited assistance of one staff for transfers. R33's care plan was reviewed and the following was noted: Problem start date: 4/02/21, Category: ADL (Activities of Daily Living) Functional/Rehabilitation potential. Short term Goal Target Date: 10/12/22: Resident will be clean and appropriately groomed and dressed daily. Approach start date: 4/20/21: using bilateral postioning rails for enhanced bed mobility and transfers. Surveyor requested and received R33's Postioning and Rail Use assessment dated [DATE]. The assessment notes: Mobility issue necessitating the need for postioning rails: left blank Rationale for use: Assist with transfers, assists with bed mobility, enhances resident awareness of bed parameter. Type of postioning device used: 1/4 rail Placement on bed: two side Frequency of use: daily When using the above indicated device, can the resident demonstrate proper use without hindering mobility: yes Risks and benefits explained to resident/resident representative and a copy of brochure provided: no, already aware, previously provided Date of risk/benefit discussion and consent for use obtained: 7/06/2022 Care plan updated to reflect the use: no, already up to date There is no evidence R33's risk for entrapment was assessed as part of the assessment. Example 2 On 7/11/22 at 10:04 AM, Surveyor observed R42's bed with positioning rails on left and right side of bed which are approximately 1/4 length of bed. On 7/12/22 at 6:29 AM, Surveyor observed R42 in bed, bed is in low position with both bed rails in upright position. On 7/13/22 at 6:32 AM, Surveyor observed R42 in bed, bed is low, both bed rails in upright position. R42's care plan was reviewed and the following was noted: Problem start date: 5/23/2022, Category: Self care deficit and mobility deficits related to weakness, poor decision making, L1 compression fracture. Short term Goal Target Date: 05/23/22: Resident requires use of two sides postioning rail for enhanced bed mobility and transfers. Of note: The date the rails were added to the care plan was noted 5/23/22; however, R42's assessment was not completed until 7/13/22, after the rails were installed. R42's most recent admission MDS dated [DATE] notes: bed mobility: 3/2 (extensive assist of one staff) transfer: 3/3 (extensive assist of 2 staff) R42's record was reviewed. Surveyor found no evidence of bed rail assessment or informed consent for use of the bed rails. Surveyor requested and received R42's Postioning and Rail Use Assessment. The assessment is dated 7/13/22. The assessment notes: Mobility issue necessitating the need for postioning rails: Spinal stenosis and lumbar fracture Rationale for use: assists with bed mobility. Type of postioning device used: 1/8 rail Placement on bed: two side Frequency of use: daily When using the above indicated device, can the resident demonstrate proper use without hindering mobility: yes Risks and benefits explained to resident/resident representative and a copy of brochure provided: yes Date of risk/benefit discussion and consent for use obtained: 7/13/2022 Care plan updated to reflect the use: yes The assessment was dated the day the Surveyor requested the assessment and does not address R42's risk of entrapment. Example 3 On 7/13/22 at 3:29 PM, Surveyor observed R51 lying in bed with bed rails on both sides of bed in upright position. Bed rails approximately 1/4 length of R51's bed. R51's care plan was reviewed and the following was noted: Problem start date: 12/08/20 Instruct and assist repositioning every 2 hours in bed, use postioning rail. R51's Quarterly MDS dated [DATE] notes: bed mobility: 3/3 (extensive assist of two staff) transfer: 3/3 (extensive assist of 2 staff) Surveyor requested and received R51's Postioning and Rail Use Assessment. The assessment is dated 7/05/2022. The assessment notes: Mobility issue necessitating the need for postioning rails: bed mobility, weakness Rationale for use: assists with transfer, assist with bed mobility, enhances resident awareness of bed perimeter. Type of postioning device used: 1/2 rail Placement on bed: two side Frequency of use: daily When using the above indicated device, can the resident demonstrate proper use without hindering mobility: yes Risks and benefits explained to resident/resident representative and a copy of brochure provided: yes Date of risk/benefit discussion and consent for use obtained: 7/01/2022, poa Care plan updated to reflect the use: no, care plan current The assessment does not assess R51's risk of entrapment. Example 4 On 7/11/22 at 10:37 AM, Surveyor observed R173 in bed with bed rails on both sides of his bed. The rails were in upright position and were approximately 1/4 length of R173's bed. R173's admission MDS dated [DATE] notes: bed mobility: 3/3 (extensive assist of two staff) transfer: 4/3 (dependent on 2 staff) R173's care plan was reviewed and the following was noted: Problem start date: 6/29/22 Category: ADL functional/rehabilitation potential Self-care deficit related to weakness due to peritonitis, perforated sigmoid colon, [CONDITION(S)], left below knee amputation, [CONDITION(S)] on [CONDITION(S)], mobility deficits left below knee amputation and [CONDITION(S)] on [CONDITION(S)]. Goal target date: 10/11/22: Resident will participate in ADL's as able to retain strength and return home. Approach start date: 6/29/22: Resident requires use of two sides, positioning rail. Surveyor requested and received R173's Postioning and Rail Use Assessment. The assessment is dated 7/01/2022. The assessment notes: Mobility issue necessitating the need for postioning rails: bed mobility, weakness Rationale for use: assists with transfer and assist with bed mobility. Type of postioning device used: 1/4 rail Placement on bed: two side Frequency of use: daily in bed positioning and transfers When using the above indicated device, can the resident demonstrate proper use without hindering mobility: yes Risks and benefits explained to resident/resident representative and a copy of brochure provided: yes Date of risk/benefit discussion and consent for use obtained: 7/01/2022 Care plan updated to reflect the use: yes The assessment does not assess R173's risk of entrapment. Example 5: Resident (R) 12 has medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12 has grab bars on each side of the bed. These bars are approximately 1 1/2 feet long x 1 1/2 feet wide at the bottom where the bar meets the mattress and thins out at the top where the individual would grab onto the bar. The top of the grab bar is rounded and measured approximately 6-7 inches. The most recently completed Minimum Data Set Assessment (MDSA) reviewed was a Quarterly assessment dated [DATE]. According to this MDSA, R12 has a Brief Interview of Mental Status (BIMS) score of 6/15, indicating severe cognitive loss. Also according to this MDSA, R12 required extensive assistance of one staff to meet his most basic daily tasks of bed mobility, dressing, toileting and personal hygiene. R12 is dependent on staff for transfers and bathing tasks. R12 was also noted to be non-ambulatory and has limitations of range of motion for both upper and lower extremities on one side of the body. According to R12's Care Plan (CP), under the area of Pressure Ulcer, the facility identified a care area of At Risk For Impaired Skin Integrity R/T (related to) weakness and need for extensive assist with ADL's (Activities of Daily Living), transfers and bed mobility as well as incontinence. RESTORATIVE: bed mobility to prevent skin breakdown. This CP had a start date of 08/09/2016 and was last reviewed/revised on 5/02/2022. For the goal of 'Skin will remain intact' the facility included to Encourage use of trapeze and bilateral grab bars for repositioning when sitting in bed. Encourage his participation. Restorative: Bed mobility-Instruct where to place hands and encourage to do as much as he can. Start Date 08/15/2016. On 07/11/22, Surveyor observed cares provided by CNA I (Certified Nursing Assistant) of perineal care while resident was in bed. During this observation, R12 was rolled to his right and left and onto his back. At no time during the observation did R12 make attempts to grab onto the grab bars which were in the up position, to assist with rolling himself in the bed. CNA I stated when asked, that R12 doesn't really make attempts to assist with repositioning. He is totally dependent on us to roll back and forth in bed. The facility completed a Positioning Rail Use Assessment on 4/29/22. The device assessed was the grab bars on each side of the bed. The grab bars were for positioning. The concern is that this assessment did not indicate the consent for use by R12 or his representative and it marked the box no for the area of Risks and benefits were explained to the resident/representative and a copy of the risk brochure was provided. There also was no indication that other less restrictive alternatives were attempted prior to placement of the grab bars, nor was there an assessment located for the potential risk for entrapment. Example 6: Resident (R) 26 has medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26 has grab bars on each side of the bed. These bars are approximately 1 1/2 feet long x 1 1/2 feet wide at the bottom where the bar meets the mattress and thins out at the top where the individual would grab onto the bar. The top of the grab bar is rounded and measured approximately 6-7 inches. The most recent MDSA completed for R26 was a Quarterly assessment dated [DATE]. According to this MDSA, R26 has a BIMS score of 15/15, indicating that he is fully cognizant. Also according to this MDSA, R26 requires extensive assistance of two staff to meet his most basic daily tasks of bed mobility, transfers, dressing, toileting and personal hygiene. R26 is totally dependent of two staff for bathing. R26 has bilaterally lower extremity range of motion limitations due to above knee amputations of both legs and is non-ambulatory. The Care Plan (CP) completed for R26 included an area for AT RISK FOR IMPAIRED SKIN INTEGRITY R/T (related to) multiple co-morbidities, has BLE (bilateral lower extremity) above knee amputations; incontinent of bladder and bowel, strength: able to turn in bed with grab bar use and reposition with trapeze use . This CP start date was 6/27/19 and was most recently reviewed/revised on 5/16/22. An intervention included in this CP was Encourage use of bilateral grab bars and trapeze, to shift self and turn in bed, encourage side lying in bed as much as possible. The start date for this intervention was 06/27/2019. The facility completed an assessment Positioning Rail Use Assessment on 6/23/22. The device assessed was the grab bars on each side of the bed. R26 consented to the use of the grab bars and risks and benefits were explained; however, there was no assessment completed to identify a potential risk for entrapment of the grab bars. Example 7 Resident (R) 65 has medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R65 has grab bars on each side of the bed. These bars are approximately 1 1/2 feet long x 1 1/2 feet wide at the bottom where the bar meets the mattress and thins out at the top where the individual would grab onto the bar. The top of the grab bar is rounded and measured approximately 6-7 inches. The most recent MDSA completed for R65 was an annual assessment dated [DATE]. According to this MDSA, R65 has a BIMS score of 10/15, indicating that he is moderately impaired cognitively. Also according to this MDSA, R65 requires extensive assistance of one staff to meet his most basic daily tasks of bed mobility, transfers, ambulation in the room, dressing, toileting use and personal hygiene. R65 is totally dependent of one staff for bathing and has range of motion limitations of both sides of his upper extremities and one side of his lower extremities. According to the Care Plan (CP) completed for R65, the facility identified a care area for AT RISK FOR IMPAIRED SKIN INTEGRITY r/t (related to) incontinence, inability to reposition self, extensive assist for transfers and bed mobility, [CONDITION(S)] disease, [CONDITION(S)]. Restorative Splint orthotic wear. The start date for this area was 09/03/2017 and was last reviewed/revised on 06/24/2022. According to this area, the facility included an intervention for grab bars to both sides of bed to aid in transfers, bed mobility/repositioning. The start date for this intervention was 11/19/2019. The facility completed an assessment titled Positioning Rail Use Assessment on 6/21/22. According to this assessment, the risks and benefits of the grab bar use was explained to R65 as well as his representative and a consent for use was obtained. The concern is that there was no assessment to determine the risk for entrapment with the use of the devices. Example 8 Resident (R) 70 has medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R70 has grab bars on each side of the bed. These bars are approximately 1 1/2 feet long x 1 1/2 feet wide at the bottom where the bar meets the mattress and thins out at the top where the individual would grab onto the bar. The top of the grab bar is rounded and measured approximately 6-7 inches. The most recent MDSA completed for R70 was a quarterly assessment dated [DATE]. According to this MDSA, R70 has a BIMS score of 15/15, indicating that she is fully cognizant. Also according to this MDSA, R70 requires extensive assistance of one staff to meet her most basic daily tasks of bed mobility, transfers, ambulation in the room, dressing, toileting use, personal hygiene and bathing. R70 has no range of motion limitations. The Care Plan (CP) for R70 included an area Self Care Deficit R/T (related to) potential for discomfort, arthritis, LLE (lower left extremity) discomfort, Right wrist discomfort. SCSA (Significant Change in Status Assessment) completed . r/t increased pain, weakness, and need for increased assistance . The start date for this area was 12/13/2019, and was last reviewed/revised on 07/12/2022. Included in the interventions for this CP was Resident requires use of two sides positioning rail for enhanced bed mobility and transfers. The start date for this intervention was 12/13/2019. The facility completed an assessment titled Positioning Rail Use Assessment on 4/6/22. According to this assessment, the risks and benefits of the grab bar use were explained to R70 and she consented to the use of the device. The concern is that the facility did not complete an assessment for the potential risk for entrapment of the device. Example 9 7/12/22 11:00 AM, observed R6 had air mattress with bilateral grab bars. R6's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS assessment dated [DATE] indicated moderately impaired cognition. Reviewed positioning rail assessment dated [DATE] indicated bilateral positioning bars for transfers and bed mobility. Risks and benefits were reviewed with R6 and R6 provided consent. R6's Power of Attorney is activated. Reviewed R6's care plan dated 10/6/21 included fall risk area and restorative program to remind R6 to use grab bars during transfers with assist of one person. Surveyor did not find documentation to support assessment for entrapment or that alternative methods were tried prior to installing R6's grab bars. Example 10 7/13/22 9:12 AM, observed R18 had bilateral grab bars on her bed. R18's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's MDS assessment dated [DATE] indicated intact cognition and supervision with ADLs. Reviewed positioning rail assessment dated [DATE] indicated bilateral positioning bars for transfers and bed mobility. Reviewed R18's care plan dated 6/8/21 included self care deficit with approaches to use one staff person to assist with transfers, and use of positioning rails for bed mobility and transfers. Surveyor did not find documentation to support assessment for entrapment or that alternative methods were tried prior to installing R18's grab bars. Example 11 7/11/22 2:00 PM, observed R28 had air mattress and bilateral grab bars. R28's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's MDS assessment dated [DATE] indicated severe cognitive impairment and two person assist with bed mobility. R28's Power of Attorney is activated. Reviewed R28's positioning rail assessment dated [DATE] indicated bilateral 1/4 rails to assist with bed mobility. Reviewed R28's care plan dated 9/24/20 included self care deficit with approach for R28 to use positioning rails for bed mobility and transfers. Surveyor did not find documentation to support assessment for entrapment or that alternative methods were tried prior to installing R6's grab bars. Example 12 7/13/22 3:35 PM, observed R58 had bilateral enabler bars. R58's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R58's MDS dated [DATE] indicated assist of one person with ADLs. Reviewed R58's positioning rail assessment dated [DATE] indicated bilateral positioning bars for assistance with transfers, bed mobility and to enhance R58's awareness of bed perimeter. Reviewed R58's care plan 3/1/22 included self care and mobility deficits with approach for R58 to use one staff person to assist with transfers and bed mobility with use of positioning rails. Surveyor did not find documentation to support assessment for entrapment or that alternative methods were tried prior to installing R6's grab bars. Example 13 7/13/22 1:31 PM, observed R60 had air mattress and bilateral enabler bars. R60's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R60's MDS assessment dated [DATE] indicated moderately impaired cognition and two person assistance with bed mobility and transfers with mechanical lift. Reviewed R60's positioning rail assessment dated [DATE] indicated bilateral positioning bars for assistance with bed mobility. Reviewed R60's care plan dated 6/11/20 included self care deficits and impaired mobility with assistance for repositioning with the use of positioning rails. Surveyor did not find documentation to support assessment for entrapment or that alternative methods were tried prior to installing R60's grab bars. Example 14 On initial tour Surveyor observed R1 having bilateral bed rails attached to the bed. Review of R1's medical record document current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Minimum Data Set (MDS) quarterly assessment date 07/02/22 documented a BIMS score of 8. A score of 8 is defined as R1 having moderately impaired cognition. The MDS documents in Section G as R1 requiring extensive assistance of two staff member for bed mobility. Review of care plan dated 03/27/20, documented Bed mobility: MAX assist x's 2 with maxi slide. Bilateral position bars. Review of the medical record identified a Position Rail Use assessment was completed on 03/20/22 for positioning with consent signed on 03/20/22. This position rail assessment did not assess for risk of entrapment. No documentation of a trial of alternate devices before placement of bed rails. Example 15 On 07/11/22 at 10:21 AM, Surveyor observed R5 having a fall mat next to bed, and bilateral grab bar with a lipped mattress. Review of R5's medical record documents current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of MDS quarterly assessment date 04/11/22 documented a BIMS score of 13. A score of 13 is defined as R5 being cognitively intact. The MDS documents in Section G as R5 requiring extensive assistance of one staff member for bed mobility. Review of care plan dated 03/02/21, documented Resident requires use of bilateral 1/4 positioning rail for enhanced bed mobility and transfers. Review of the medical record identified a bed rail assessment was completed on 02/18/21 for positioning with consent signed on 02/17/21. This bed rail assessment did not assess for risk of entrapment. No documentation of a trial of alternate devices before placement of bed rails. Example 16 On 07/11/22 on initial tour, Surveyor observed R11 having bilateral grab bar with an air mattress. Review of R11's medical record document current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS significant change assessment date 04/25/22, a BIMS documented R11 as having moderately impaired cognitive skills and poor decisions with needing cues and require supervision. Review of care plan dated 05/03/19, documented Resident requires use of positioning rails for enhanced bed mobility. Review of the medical record identified a bed rail assessment was not completed for risk of entrapment. No documentation of a trial of alternate devices before placement of bed rails. Example 17 On 07/11/22 on initial tour, Surveyor observed R36 having bilateral bed rail. On 07/11/22 at 9:59 AM, Surveyor interviewed R36 about the use of the bed rail. R36 indicated will use the grab bars to get in and out bed. Review of R36's medical record document current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a fall risk assessment completed on 4/18/22, documented a fall risk score of 15 and being at risk for falls. Review of the MDS significant change assessment date 05/18/22 documented a BIMS score of 9. A score of 9 is defined as R36 having moderately impaired cognition. The MDS documents in Section G as R36 requiring extensive assistance of two staff member for bed mobility. Review of care plan did not identify use of bed rail. Review of the medical record identified a bed rail assessment was not completed for risk of entrapment. No documentation of a trial of alternate devices before placement of bed rails. On 07/13/22 at 1:50 PM, Surveyor interviewed DON B asking for a bed rail assessment for R36. DON B indicated there is no assessment for bed rail. Example 18 On 07/11/22 on initial tour, Surveyor observed R41 having bilateral grab bar with an air mattress. Review of R41's medical record document current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS admission assessment date 05/24/22, a BIMS documented score of 12. A score of 12 is defined as R41 being cognitively intact. The MDS documents in Section G as R41 requiring extensive assistance of two staff member for bed mobility. Review of the care plan documented on 05/19/22 Resident requires use of two sides, positioning rail for enhanced bed mobility and transfers. Review of the medical record identified on 05/20/22 a positioning rail use assessment was completed. This assessment did not assess for risk of entrapment. No documentation of a trial of alternate devices before placement of bed rails. On 7/13/22 at 2:28 PM, Surveyor spoke with Director of Nursing (DON) B regarding the facility process for installing and assessing resident bed rails as well as evidence of alternative methods attempted prior to installing the rails. DON B indicated essentially all beds in the facility have positioning rails. Assessment of rails is done by therapy when residents are admitted , looking at need for the rails to aide with positioning. If there is a risk with having the rails, it is addressed. The rails are generally placed on resident care plans based on the resident need. Informed consent is obtained verbally and noted on the assessment. The risk of resident entrapment is not part of the facility assessment.

Based on interview and record review, the facility did not promote and facilitate resident self-determination through support of resident choice for 1 (Resident (R) 11) of 18 residents reviewed. R11 was not given the right to choose to decline the medication of [MEDICATION(S)] as this was ordered to be given in a drink. This is evidenced by: Review of R11's medical record documented current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) significant change assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) with R11 as having moderately impaired cognitive skills and poor decisions with needing cues and requires supervision. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 04/18/22: [MEDICATION(S)] concentrate - Schedule II, solution; 100 mg/5 mL (20 mg/mL); amt: .25-1ml=5-20mg; sublingual, Every 2 Hours - PRN PRN 1, PRN 2, PRN 3, PRN 4, PRN 5, PRN 6, PRN 7, PRN 8, PRN 9, PRN 10, PRN 11, PRN 12 04/22/22 Medication Administration Special Instructions: Trusted CNA may administer meds to resident that have been prepared by nurse and administered under supervision of nurse out of site of resident Per Dr. [Name]. [MEDICATION(S)] may also be given in Pepsi without resident's knowledge per POA and Dr. [Name]. Every Shift shift 1, shift 2, shift 3. Review of care plan documented, in part: 05/01/22: Problem: Resident has Lewy Body Dementia with Behavioral Disturbances Goal: Resident behaviors will be minimized by care plan approaches and ordered medications Target Date: 08/01/2022 (Long Term Goal) 5/1/22. Approach: *Medication Administration: While under supervision of a licensed nurse, ABH cream may be mixed with body lotion and applied by staff. My medications may be crushed by licensed staff and placed in my food or liquids without my knowledge per my POA and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 07/13/22 at 1:20 p.m., Surveyor interviewed Director of Nursing (DON) B asking if R11 has a court order to give medication in food or fluids without R11's knowledge and denying R11 the choice to take the medication. DON B indicated the physician and the Power of Attorney (POA) requested the medication to be given in Pepsi. DON B indicated the facility did not have a court order to give medication to R11 without knowledge and the order has been removed. The physician has been updated.

Based on observation, interview and record review, the facility did not provide Activities of Daily Living (ADL) for 2 of 3 residents (R33 and R60) reviewed, who are unable to carry out the necessary services. R33 requires staff assistance to shower. R33 was not consistently provided a weekly shower as preferred. R60 did not receive weekly assistance with a bath or shower. This is evidenced by: 1. On 7/11/22 at 1:32 PM, Surveyor spoke with R33. R33 indicated she has not had a shower in past couple of weeks due to issues with the facility's hot water boiler and staffing issues. R33 also expressed she is scheduled to get a shower one time a week on the morning shift on Thursdays. R33 expressed she depends on staff to assist her in and out of the shower and help her wash up as she is unable to do so herself. R33 expressed she would like at least a weekly shower as her hair gets greasy and she does not feel clean. R33 expressed she often does not get a weekly shower as there is not enough staff to help her. R33 further expressed she does not like her hair greasy and it should be washed at least weekly. R33 expressed it has been several months that she has not consistently received a weekly shower. Surveyor noted R33's hair up in hair clip. R33's hair was disheveled and appeared greasy. On 7/12/22 at 12:04 PM, R33 was observed in the dining room. R33 hair's was down and was clean in appearance. Surveyor reviewed R33's most recent Minimum Data Set (MDS) assessment which was a quarterly dated 7/07/22. The MDS notes R33 understands, is understood, is cognitively intact and requires physical help of one staff to shower. R33's quarterly MDS dated [DATE] notes R33 is dependent on 1 staff to shower, is understood, understands and is cognitively intact. R33's care plan was reviewed, and the following was noted: Self-care deficit related to pain and weakness Goal: Will be clean and appropriately groomed/dressed daily Start date: 5/24/21, Target date: 10/12/22 Approach: Bathing: UE (Upper Extremity)-Supervision, LE (Lower Extremity)-Extensive Assist, both R33's shower data was reviewed from January 1, 2022, to present. The data shows the following: January 2022 showers provided: 1/06, 1/13/, 1/20 and 1/27/2022 February 2022 showers provided: 2/03/22 March 2022 showers provided: 03/03 (1 month since prior shower), 3/10, and 3/24/22 (14 days since prior shower) April 2022 showers provided: 4/07 (14 days since prior shower), 4/14 and 4/21/22 May 2022 showers provided: 5/05 (14 days since prior shower), 5/19 (14 days since prior shower) and 5/27/22 June 2022 showers provided: 6/09 (12 days since prior shower), 6/18 (9 days since prior shower), 6/23/22 July 2022 showers provided: 7/12/22 (19 days since prior shower) On 07/13/22 at 9:03 AM, Surveyor spoke with Certified Nursing Assistant (CNA) C, who has been on staff approximately 2 years and is familiar with R33. CNA C indicated R33 requires assistance of staff to shower. CNA C verified R33 is scheduled to receive a weekly shower on Thursday mornings via the staff shower list. CNA C expressed R33 does not refuse to shower. Staff would record refused for residents who refuse showers. Data showed activity did not occur which means a shower was not offered. Surveyor asked CNA C why R33 was not assisted with a shower weekly. CNA C was joined by CNA (D) who has been on staff a little over a month. CNA C and CNA D indicated they are often unable to get showers completed for residents on the 100 wing as the unit has 18-25 residents and is often scheduled with only 1 CNA which is not enough staff to complete showers as needed. On 07/13/22 at 9:10 AM, Surveyor spoke with Registered Nurse (RN) E, who has been on staff several years and oversees the CNAs on the 100 wing. RN E indicated the facility has had intermittent issues with hot water for a few months that has gotten worse the past 2 weeks or so. The water would go cold on occasion but would only last a couple hours than be fine for several days. The issues with showers not being given is not related to the water issue. The resident showers not being given is related to the 100 wing often being staffed with 1 certified nursing assistant on day shift. RN E expressed she often helps the nurse aides assist residents with ADLs but there is only so much she can do without impacting her nursing duties. Surveyor shared R33's shower information with RN E. RN expressed R33 does not refuse showers and it is important to her to get showers. R33's hair gets greasy and it's not good that she has to go so long in between showers. 2. R60 required assistance with ADLs including bathing. R60 did not receive weekly assistance with bathing. This is evidenced by: R60 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS assessment dated [DATE] indicated R60 had adequate speech, hearing and ability to understand others. Assistance required; total assistance with bathing. R60's care plan dated 6/21/22 included a focus areas of: Self Care Deficit and Impaired Physical Mobility related to history of covid positive, falls, and impaired coordination. Interventions included extensive assistance with bathing and skin inspection with weekly bath. R60 uses a shower chair with armrests. On 7/11/22, Surveyor observed R60 lying in bed with covers over her. R60's hair was observed to be oily and unkempt. Surveyor attempted an interview with R60 but she declined and asked Surveyor to come back the following day. On 7/12/22 at 9:30 AM, Surveyor observed two CNAs use mechanical hoyer lift to transfer R60 to her wheelchair. R60 was dressed in long pants and long sleeve shirt. R60's hair was combed and oily. R60 was attending an activity and declined an interview at that time. Surveyor reviewed R60's shower documentation and noted R60 received scheduled shower or bed baths 15 of 23 weeks. There was no documentation indicating R60 refused bathing or showering. Confirmed the following: -2/14 bed bath -2/24 shower (10 days since last shower) -3/3 bed bath -3/10 shower -3/17 partial bed bath -3/25 shower -3/31 shower -4/14 shower (two weeks since last shower). -5/5 shower (three weeks since last shower). -5/19 bed bath (two weeks since last shower) -5/26 shower -6/2 bed bath -6/16 bed bath (two weeks since last shower). -6/23 bed bath -7/8 shower (two weeks since last shower). On 07/13/22 at 10:28 AM, interview with CNA G reported that R60 receives weekly shower on Thursday evenings. CNA G was unsure if R60 refuses showers as she does not work the evening shift. CNA G stated that facility policy for resident refusal is to encourage resident at a later time or the following day. On 07/13/22 at 1:31 PM, interview with R60 regarding assistance with bathing and showering. R60 was in her room, sitting in her wheelchair. R60 is dressed in long pants and a long sleeve shirt. Her hair is combed and oily. R60 reported that she has not received a shower in weeks, that she has received a bed bath but staff do not wash her feet or hair. R60 indicated no refusals and that she would prefer a weekly shower and not a bed bath. On 07/13/22 at 1:44 PM, interview with CNA H, stated that resident received a shower on Friday (7/8), from an evening shift CNA.

Based on record review and interview, the facility did not immediately consult with the resident's physician when there was a significant change in the resident's physical status, or when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) in 1 of 3 residents reviewed (R1). The facility did not contact a Physician when R1's fluid intake was less than 50% of recommended values to maintain proper hydration for 4 of 5 days prior to hospitalization . Upon hospitalization R1's renal function was impaired, creatinine was 2.47 and Blood Urea [MEDICATION(S)] (BUN) increased to 81. Hospital discharge records dated 6/29/21 indicate R1 suffered Acute Kidney injury. R1 was hospitalized with acute kidney injury and an elevated creatinine and blood urea [MEDICATION(S)] levels requiring intravenous hydration. This is evidenced by: R1 was admitted to the facility on [DATE]; diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 resided in facility 06/02/2021 through 06/22/2021, at which time R1 was hospitalized for 7 days. Surveyor reviewed R1's medical record for hydration status during the initial 20 days in facility. R1 made her own healthcare and treatment decisions. R1's advance directive indicated Full Code. R1's admission Minimum Data Set (MDS) assessment, dated 06/07/2021, indicated R1 required supervision-oversight, encouragement or cueing assistance with support of 1-person physical assist for eating and drinking; no functional range of motion impairment in upper extremities. Height: 60 inches. Weight: 133 pounds. R1's Hydration assessment dated [DATE], indicated Dehydration Risk Score: 2 Level: Not at risk R1's Admission Nutritional assessment dated [DATE], indicated .Total fluids required to meet estimated needs .1200-1400cc R1's Hydration assessment dated [DATE], indicated Dehydration Risk Score: 21 Level: At risk R1's Care Plan dated 06/02/2021, read: Problem: Potential for alteration in nutrition: Resident has good appetites, tolerates diet and weight is within desired body weight. Goal: Resident will maintain adequate nutritional status as evidenced by stable weight and good appetite. Approach: Provide general diet per MD order. R1's Care Plan was updated to include: At nutritional risk r/t poor appetite. At risk for dehydration r/t recent UTI .Resident will maintain adequate nutritional status as evidenced by stable weight ~130-140# and good appetite >50% at most meals. Will accept supplements. No s/s of dehydration. Interventions added: 06/02/2021 Provide general, regular, thin liquids diet .06/07/2021 Provide house supplement TID with all meals .06/15/2021 Intake monitoring with goal of 1500cc/day. Monitor for s/s of dehydration. Offer fluids with each encounter R1 also had Care Plans for the following: Urinary Incontinence: Risk for Infection. Interventions for these included: 06/13/2021: Encourage fluids with meals and with each encounter R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On 06/17/21 the physician ordered a 1500 milliliter fluid goal. R1's Nursing Orders included: 06/02/2021-06/05/2021: Check hydration status and chart results x3 days. Special Instructions: Oral mucosa, skin turgor, skin condition, offering fluids and snacks. Every shift; 06/17/2021: Monitor fluids every shift (goal 1500ml) Nursing notes in part, 06/03/21 .admitted status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing notes revealed staff recorded daily narrative notes indicating clinical s/s of hydration status every day: 06/2/2021 through 06/11/2021, notes indicate oral mucosa pink and moist, no tenting of skin, fluids are at bedside and encouraged. 06/07/2021 R1 was evaluated by Speech Therapy: Speech screen completed on new admission. The Pt's expressive/receptive language skills were functional in conversation. Pt reported that she is not having any difficulty chewing or swallowing. During the screen, the Pt swallowed sips of water safely without any s/s of aspiration. Speech therapy is not indicated at this time. 06/11/2021 Urinalysis and Culture & Sensitivity is collected in preparation of upcoming surgery to remove kidney stone and [CONDITION(S)] stent; upon lab results, R1 was diagnosed with a Urinary Tract Infection (UTI) and subsequently started on an antibiotic, [MEDICATION(S)]. 06/12/2021: .oral mucosa and lips slightly dry, no [NAME] to tongue, no tenting to skin, drinking fluids well for this writer 06/13/2021: .oral mucosa and lips slightly dry, no [NAME] to tongue, no tenting to skin, drinking fluids well for this writer, did not eat dinner but did drink chocolate Ensure, declined multiple offer for alternatives, snacks . 06/15/2021 through 06/19/2021 notes indicate oral mucosa pink and moist, no tenting of skin, fluids are at bedside and encouraged. 06/20/21 22:45 [10:45 p.m.] .skin turgor without prolonged tenting. Fluids available at bedside and encouraged . 06/21/2021: .tongue is very dry and furrowed, is breathing through mouth more, daughters here this evening and assisting with oral intake as well as C.N.A. writer was able to give 300cc water with med passes, she also sipped on juice, and soda. Took 520cc in, no tenting noted to skin. Lip balm applied to lips. Did review with C.N.A.'s to provide Ensure if eating 25% or less of meal. On 06/21/21 R1 had a very dry and furrowed tongue which is a symptom of dehydration. The physician was not notified of this change in condition. **On 06/17/2021 Fluid monitoring was implemented with a goal of 1500cc/day. No fluid intakes were recorded prior to 06/17/2021. 06/17/2021 Fluids: 480mL 06/18/2021 Fluids: 60mL 06/18/2021 Fluids: 120mL 06/18/2021 Fluids: 240mL 06/19/2021 Fluids: 60mL 06/19/2021 Fluids: 360mL 06/19/2021 Fluids: 120mL 06/20/2021 Fluids: 100mL 06/20/2021 Fluids: 240mL 06/20/2021 Fluids: 320mL 06/21/2021 Fluids: 100mL 06/21/2021 Fluids: 180mL 06/21/2021 Fluids: 520mL **All other meals/dates are recorded as None, or not recorded at all. The total amount of fluid intake per day was not calculated by the facility. The total amount of fluid intake per day, calculated by Surveyor, showed: 06/17/2021: Daily Total: 480mL 06/18/2021: Daily Total: 420mL 06/19/2021: Daily Total: 540mL 06/20/2021: Daily Total: 660mL 06/21/2022: Daily Total: 800mL The American Medical Director's Association (AMDA), Acute Change of Condition in the Long Term Care Setting guideline identifies that a decreased oral intake of fluids of less than 50% of the usual fluid intake in previous 24 hours should be reported to the practitioner immediately. R1's intake of fluids less than 50% of usual fluid intake on 06/17 - 06/20/21 were not reported to the physician. 06/22/2021 R1 was assessed by Nurse Practitioner (NP) at request of nursing staff due to reddened area on coccyx. Nursing Home Visit note dated 06/22/2021, read: .her daughter in the room with concerns that for 3 days her mother has been very tired and has not eaten. She has been taking fluids but no food intake-she states has no appetite-this is a change from her usual. Having a difficult time getting her to answer questions-she is awake but lethargic/speech thick. She states she is thirsty and taking sips of fluid .blood pressure low this morning but she has had labile readings-occasional low blood pressure readings as well as elevated BP .I recommend that she be sent to the emergency department-I am concerned about her decline, low BP and possible [CONDITION(S)] . emergency room note dated 06/22/2021, read: .The patient is a 91-year female brought in by ambulance for altered mental status and [CONDITION(S)] .nurse practitioner was concerned for the possibility of [CONDITION(S)] .for the last 3 days staff noted that patient has had increasing lethargy decreasing appetite .Physical Exam .ENMT .Moist MM (mucous membranes) .Vital signs: blood pressure 127/60, pulse 78 .Labs: .Patient's renal function was impaired creatinine was 2.47 .BUN increased to 81 .Patient was bolused with 500cc of normal saline and started on broad-spectrum antibiotics .Patient tolerated the 500 cc bolus without difficulty. She was bolused an additional 1.5 L(Liter) of normal saline. Patient completed a total of 2L without difficulty with known renal failure. Additional 1 L of [MEDICATION(S)] Ringer's was initiated. This case was discussed with the on-call urologist .based on patient's CT scan of the abdomen from this morning this patient does not need to be transferred to hospital with urological services. Patient can be admitted and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] .Impression: Patient's presentation is not entirely consistent with [CONDITION(S)] .however given the concern of .altered mental status could be explained by per past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan: Admit to hospital for IV antibiotics and serial creatinine. R1's baseline lab values from 06/02/21 were Creatinine 0.9 and Blood Urea [MEDICATION(S)] 26. R1 recovered and returned to facility on 06/29/2021. Discharge Summary dated 06/29/2021 for hospital stay 06/22/2021-06/29/2021, read, in part: .1 .started on empiric antibiotics for questionable UTI: however urine culture did not have any significant growth. IV antibiotics were subsequently stopped .2. Acute Kidney injury. Creatinine of 2.5 at time of admission compared to baseline of around 1. With aggressive IV fluid hydration, creatinine improved to 0.7 as of now . Urine culture subsequently negative On 07/20/2021, Surveyor met with Director of Nursing (DON) B and Nursing Home Administrator (NHA) A, who stated the facility did not have a system in place for tracking daily intakes to ensure they meet the resident's needs. Beginning 06/07/2021, a house supplement was placed on R1's meal tray for all meals, but no information was logged for percentage consumed. Beginning 06/17/2021, staff recorded R1's fluid intakes, but did not total them daily to ensure the 1500cc/day intake goal was met. DON B and NHA A presented Surveyor with a Performance Improvement Project (PIP) dated 7/14/2021 in which the facility identified documentation related to nutrition/hydration status as a problem and physician notification related to hydration. The PIP was initiated subsequent to the survey entrance.

Based on interview and record review, the facility did not ensure 1 of 3 residents (R1) reviewed was offered sufficient fluid intake to maintain proper hydration and health. The facility did not have a system in place for tracking daily intakes to ensure they meet the resident's needs. R1's fluid intake was less than 50% of recommended values to maintain proper hydration for 4 of 5 days prior to hospitalization . Upon hospitalization , R1's renal function was impaired, creatinine was 2.47 and Blood Urea [MEDICATION(S)] (BUN) increased to 81. Hospital discharge records dated 6/29/21 indicate R1 suffered an Acute Kidney injury. Findings include: R1 was admitted to facility on 06/02/2021; diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 resided in facility 06/02/2021 through 06/22/2021, at which time R1 was hospitalized for 7 days. Surveyor reviewed R1's medical record for hydration status during the initial 20 days in facility. R1 made her own healthcare and treatment decisions. R1's advance directive indicated Full Code. R1's admission Minimum Data Set (MDS) assessment, dated 06/07/2021, indicated R1 required supervision-oversight, encouragement or cueing assistance with support of 1-person physical assist for eating and drinking; no functional range of motion impairment in upper extremities. Height: 60 inches. Weight: 133 pounds. R1's Hydration assessment dated [DATE], indicated Dehydration Risk Score: 2 Level: Not at risk R1's Admission Nutritional Assessment, dated 06/07/2021, indicated .Total fluids required to meet estimated needs .1200-1400cc R1's Hydration assessment dated [DATE], indicated Dehydration Risk Score: 21 Level: At risk R1's Care Plan dated 06/02/2021, read: Problem: Potential for alteration in nutrition: Resident has good appetites, tolerates diet and weight is within desired body weight. Goal: Resident will maintain adequate nutritional status as evidenced by stable weight and good appetite. Approach: Provide general diet per MD order. R1's Care Plan was updated to include: At nutritional risk r/t poor appetite. At risk for dehydration r/t recent UTI .Resident will maintain adequate nutritional status as evidenced by stable weight ~130-140# and good appetite >50% at most meals. Will accept supplements. No s/s of dehydration. Interventions added: 06/02/2021 Provide general, regular, thin liquids diet .06/07/2021 Provide house supplement TID with all meals .06/15/2021 Intake monitoring with goal of 1500cc/day. Monitor for s/s of dehydration. Offer fluids with each encounter R1 also had Care Plans for the following: Urinary Incontinence: Risk for Infection. Interventions for these included: 06/13/2021: Encourage fluids with meals and with each encounter R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Nursing Orders included: 06/02/2021-06/05/2021: Check hydration status and chart results x 3 days. Special Instructions: Oral mucosa, skin turgor, skin condition, offering fluids and snacks. Every shift; 06/17/2021: Monitor fluids every shift (goal 1500ml) Nursing notes in part: 06/03/21 .admitted status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing notes revealed staff recorded daily narrative notes indicating clinical signs and symptoms (s/s) of hydration status every day: 06/2/2021 through 06/11/2021. Notes indicate oral mucosa pink and moist, no tenting of skin, fluids are at bedside and encouraged. 06/07/2021 R1 was evaluated by Speech Therapy: Speech screen completed on new admission. The Pt's expressive/receptive language skills were functional in conversation. Pt reported that she is not having any difficulty chewing or swallowing. During the screen, the Pt swallowed sips of water safely without any s/s of aspiration. Speech therapy is not indicated at this time. 06/11/2021 Urinalysis and Culture & Sensitivity is collected in preparation of upcoming surgery to remove kidney stone and [CONDITION(S)] stent; upon lab results, R1 was diagnosed with a Urinary Tract Infection (UTI) and subsequently started on an antibiotic, [MEDICATION(S)]. 06/12/2021: .oral mucosa and lips slightly dry, no [NAME] to tongue, no tenting to skin, drinking fluids well for this writer 06/13/2021: .oral mucosa and lips slightly dry, no [NAME] to tongue, no tenting to skin, drinking fluids well for this writer, did not eat dinner but did drink chocolate Ensure, declined multiple offer for alternatives, snacks . R1 had symptoms of dehydration on 06/12 and 06/13/21 exhibited by having oral mucosa and lips that are slightly dry. 06/15/2021 through 06/19/2021 notes indicate oral mucosa pink and moist, no tenting of skin, fluids are at bedside and encouraged. 06/20/21 22:45 [10:45 p.m.] .skin turgor without prolonged tenting. Fluids available at bedside and encouraged . 06/21/2021: .tongue is very dry and furrowed, is breathing through mouth more, daughters here this evening and assisting with oral intake as well as C.N.A. writer was able to give 300cc water with med passes, she also sipped on juice, and soda. Took 520cc in, no tenting noted to skin. Lip balm applied to lips. Did review with C.N.A.'s to provide Ensure if eating 25% or less of meal. Surveyor reviewed R1's food and fluid intake. The facility did not monitor R1's fluid intake until 06/17/21 despite the fact that R1 was at risk for dehydration due to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Surveyor reviewed R1's Intake Log 06/02/2021 through 06/22/2021: 06/03/2021 Breakfast: 1-25% 06/03/2021 Dinner: 1-25% 06/07/2021 Lunch: 1-25% 06/08/2021 Dinner: 26-50% 06/12/2021 Dinner: 1-25% 06/13/2021 Lunch: 1-25% 06/14/2021 Breakfast: 1-25% 06/15/2021 Breakfast: 1-25% **On 06/17/2021 Fluid monitoring was implemented with a goal of 1500cc/day. No fluid intakes were recorded prior to 06/17/2021. 06/17/2021 Fluids: 480mL 06/18/2021 Fluids: 60mL 06/18/2021 Fluids: 120mL 06/18/2021 Fluids: 240mL 06/19/2021 Fluids: 60mL 06/19/2021 Fluids: 360mL 06/19/2021 Fluids: 120mL 06/20/2021 Fluids: 100mL 06/20/2021 Fluids: 240mL 06/20/2021 Fluids: 320mL 06/21/2021 Fluids: 100mL 06/21/2021 Fluids: 180mL 06/21/2021 Fluids: 520mL **All other meals/dates are recorded as None, or not recorded at all. The total amount of fluid intake per day was not calculated by the facility. The total amount of fluid intake per day, calculated by Surveyor, showed: 06/17/2021: Daily Total: 480mL 06/18/2021: Daily Total: 420mL 06/19/2021: Daily Total: 540mL 06/20/2021: Daily Total: 660mL 06/21/2022: Daily Total: 800mL The American Medical Director's Association (AMDA), Acute Change of Condition in the Long Term Care Setting guideline identifies that a decreased oral intake of fluids of less than 50% of the usual fluid intake in previous 24 hours should be reported to the practitioner immediately. 06/22/2021 R1 was assessed by Nurse Practitioner (NP) at request of nursing staff due to reddened area on coccyx. Nursing Home Visit note dated 06/22/2021, read: .her daughter in the room with concerns that for 3 days her mother has been very tired and has not eaten. She has been taking fluids but no food intake-she states has no appetite-this is a change from her usual. Having a difficult time getting her to answer questions-she is awake but lethargic/speech thick. She states she is thirsty and taking sips of fluid .blood pressure low this morning but she has had labile readings-occasional low blood pressure readings as well as elevated BP .I recommend that she be sent to the emergency department-I am concerned about her decline, low BP and possible [CONDITION(S)] . emergency room note dated 06/22/2021, read: .The patient is a 91-year female brought in by ambulance for altered mental status and [CONDITION(S)] .nurse practitioner was concerned for the possibility of [CONDITION(S)] .for the last 3 days staff noted that patient has had increasing lethargy decreasing appetite .Physical Exam .ENMT .Moist MM (mucous membranes) .Vital signs: blood pressure 127/60, pulse 78 .Labs: .Patient's renal function was impaired creatinine was 2.47 .BUN increased to 81 .Patient was bolused with 500cc of normal saline and started on broad-spectrum antibiotics .Patient tolerated the 500 cc bolus without difficulty. She was bolused an additional 1.5 L(Liter) of normal saline. Patient completed a total of 2L without difficulty with known renal failure. Additional 1 L of [MEDICATION(S)] Ringer's was initiated. This case was discussed with the on-call urologist .based on patient's CT scan of the abdomen from this morning this patient does not need to be transferred to hospital with urological services. Patient can be admitted and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] .Impression: Patient's presentation is not entirely consistent with [CONDITION(S)] .however given the concern of .altered mental status could be explained by per past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan: Admit to hospital for IV antibiotics and serial creatinine. CT Abdomen pelvis 1. Interval progression of right [CONDITION(S)] calculus 10mm to the lower level of the mid ureter .No hydronephrosis noted. 2. Non-obstructing left sided nephrolithiasis. R1's baseline lab values from 06/02/21 were Creatinine 0.9 and Blood Urea [MEDICATION(S)] 26. R1 recovered and returned to facility on 06/29/2021. Discharge Summary dated 06/29/2021 for hospital stay 06/22/2021-06/29/2021, read, in part: .1.Acute Metabolic [CONDITION(S)] .started on empiric antibiotics for questionable UTI: however urine culture did not have any significant growth. IV antibiotics were subsequently stopped .2. Acute Kidney injury. Creatinine of 2.5 at time of admission compared to baseline of around 1. With aggressive IV fluid hydration, creatinine improved to 0.7 as of now . Urine culture subsequently negative as mentioned above . On 07/20/21 at 11:30 a.m., Surveyor interviewed nursing staff about R1's ability to eat and drink. Nursing staff indicated R1 would eat meals in their room and was able to feed herself. R1 always had a pitcher of water within reach and was able to drink by herself and also would ask for help. Nursing staff did not recall R1 having dry mouth or cracked lips. Nursing staff indicated when assisting R1 with cares or repositioning staff would ask R1 if she needed a drink or R1 would ask staff to assist. R1 would only take sips of water at a time. Nursing staff indicated over the R1's stay in the facility it was a notable decline in R1's health and needing more assistance with meals. The Assistant Director of Nursing would assist R1 with her meal. Nursing staff indicated at the time of admission R1 ate very little to 25% of the meal and started to refuse meals. On 07/20/2021, Surveyor met with Director of Nursing (DON) B and Nursing Home Administrator (NHA) A, who stated the facility did not have a system in place for tracking daily intakes to ensure they meet the resident's needs. Beginning 06/07/2021, a house supplement was placed on R1's meal tray for all meals, but no information was logged for percentage consumed. Beginning 06/17/2021, staff recorded R1's fluid intakes, but did not total them daily to ensure the 1500cc/day intake goal was met. DON B and NHA A presented Surveyor with a Performance Improvement Project (PIP) dated 7/14/2021 in which the facility identified documentation related to nutrition/hydration status as a problem. The PIP was initiated subsequent to the survey entrance.

Based on staff interviews and record review the facility did not ensure that 1 of 2 residents (R84) received funds from their resident trust account. On 10/07/18, R84 discharged from the facility with a balance of $238.00 in his resident trust account. R84 did not receive the trust account balance upon discharge and did not give permission for the balance to be applied to his bill. This is evidenced by: R84 was admitted on [DATE] and discharged home on[DATE]. R84 was responsible for himself. According to the facility's documentation, R84 had a balance of $238.00 in his resident trust account. On 04/03/19 at 8:06 AM, Surveyor spoke with R-A (Receptionist). R-A said she sets up the resident trust account for the resident in an interest bearing account. R-A said she would give the resident a check if they had money left in their account upon discharge or soon after they leave. Surveyor spoke again with R-A at 9:09 AM and asked about R84's account. R-A said that she had issued a check to Rennes corporate office from R84's account in the amount of $238.00. R-A said R84 owed money to Rennes for his stay. R-A showed Surveyor R84's resident trust account statement which showed a check payment on 10/31/18 for $238.00 from R84's account. On 04/03/19 at 12:39 PM, Surveyor spoke again with R-A. R-A was asked if she sent or gave R84 a trust fund statement when he discharged . R-A said she did not. R-A said corporate would have sent the bill with the check number and the amount of $238.00 to R84. Surveyor asked how R84 would have known the money came from the his resident trust account. R-A said R84 would not have known unless he knew how much he had in his account. On 04/03/19 at 1:18 PM, Surveyor spoke with CDO-B (Corporate Director of Operations). CDO-B stated the facility should have given R84 a check from his resident trust account when R84 left and they didn't. 04/04/19 at 7:15 AM, Surveyor interviewed CDO-B again. CDO-B indicated that if a resident has under $30 dollars in their resident trust fund when they leave, they are to be given cash. If they have over $30, a check should be written out to them. CDO-B indicated if a resident has an outstanding bill, they should be asked if they want the amount applied to their outstanding bill. CDO-B said she wasn't sure if staff are asking that question. Surveyor asked CDO-B for the resident trust fund agreement for R84.

Based on observation, interview, and record review the facility did not ensure 1 of 1 sampled residents (R1) received the necessary care and treatment to prevent the development of a pressure injury after a splint was applied. On 6/3/17 R1 sustained 3 fractures to the left most distal (closest to the ankle) fibula following a fall. R1 returned from the emergency room with a splint. From the time the splint was applied on 6/4/17 until 6/13/17 when R1 was seen in the orthopedic clinic, the facility did not remove R1's splint and inspect the skin underneath. R1 subsequently developed an unstageable pressure injury noted as stable eschar (devitalized tissue) to the back of R1's left heel. On 7/25/17, R1's unstageable left heel pressure injury was noted to have a small open area with associated drainage. This indicated R1's pressure injury had deteriorated and was considered unstable eschar. Findings. Surveyor completed a review of R1's clinical record and noted the following. R1 had current [DIAGNOSES REDACTED]. R1's most current MDS (Minimum Data Set) was dated 6/14/17. The MDS was noted as a significant change in condition MDS. The MDS indicated R1 was cognitively intact, required extensive to total assistance of two or more staff persons for all aspects of care except eating, did not walk, had almost constant pain rated at 10 on a 0 to 10 pain scale, at risk for the development of a pressure injury, and had one unstageable pressure injury. R1's skin care plan was dated 10/20/16. The care plan had the following approaches. ~ 10/20/16, .heels up cushion . R1's CNA (Certified Nursing Assistant) care plan had an undated approach which indicted, .left leg Must be elevated keep heel up cushion .or pillow .under her calf and knee . According to R1's nursing notes on 6/3/17 R1 had a fall and sustained a [MEDICAL CONDITION] distal (closest to the ankle) part of R1's fibula. R1 was sent to the emergency room and returned to the facility with a splint on the left leg which was held in place by ace wraps. Surveyor reviewed all physician progress notes [REDACTED]. Surveyor completed a review of R1's TAR (Treatment Administration Record) from 6/1/17 through 6/14/17. The TAR indicated on 6/5/17 staff were to .Monitor for skin irritation or breakdown under splint to LLE (Left Lower Extremity) . This indicated staff were to check and inspect all skin under R1's splint. Surveyor completed a review of R1's nursing notes and noted the following. ~ 6/13/17, .returned from Ortho appointment with NNO (No New Orders) and the following progress note .c/o (complained of) poor sleep and ankle pain .3 cm (3.0 centimeters) unstageable pressure sore on back of heel: no infection .short leg cast applied .Elevate at all time to control swelling No pressure under left heel. Keep pillows or blankets supporting calf and knee but not under heel . R1's TAR directed staff to remove R1's splint. There was no indication the facility ever removed R1's splint prior to R1's orthopedic clinic appointment on 6/13/17. Within 9 days, (from 6/4/17 to 6/13/17), R1 developed an unstageable pressure injury to the left heel. The above nursing note indicated the pressure injury was identified by the orthopedic clinic and not facility staff. Surveyor requested wound notes from 6/4/17 through 6/13/17 describing R1's left heel pressure injury. None were received. On 7/26/17 at 10:20 a.m. Surveyor spoke with LPN-E. LPN-E indicated she was the nurse working on the unit in which R1 resided after R1 returned to the facility with a fractured ankle. LPN-E indicated R1 had a hard splint that was placed under R1 lower leg which extended around to heel to the bottom of the foot. LPN-E indicated the splint was secured with ace wraps. LPN-E indicated she never removed the splint. LPN-E stated she inspected R1's skin the best she could and peeked underneath the wraps. LPN-E also indicated initially R1 was in a wheel chair that did not support her left leg well and it was difficult to elevate the left leg. LPN-E indicated R1 did receive a different wheel chair that offered better support. On 7/25/17 at 4:00 p.m. Surveyor spoke with LPN-A. LPN-A indicated it was the facility's practice to remove all removable braces and splints in order to inspect all skin under the brace or splint. LPN-A indicated the physician orders [REDACTED]. LPN-A also indicated if there were no orders obtained regarding the removal of a splint and there were questions regarding the removal the physician should be contacted for clarification. On 7/26/17 at 10:34 a.m. Surveyor spoke with RN-C. RN-C indicated she was the nurse manager on the unit in which R1 resided. RN-C indicated it was the facility's practice to remove all removable braces and splints to inspect the skin beneath to ensure there were no skin problems. RN-C indicated she thought R1's splint was not removable. RN-C stated however there was no instruction from a physician on whether or not R1's splint could be removed or if it was to remain in place. RN-C indicated she was aware the splint had never been removed. RN-C indicated she had not contacted R1's physician for clarification. RN-C indicated in hind sight we should have. Nursing notes continue. ~ 6/15/17, .L (left) leg .Toes are swollen .Spoke with .Ortho .states .continue to elevate and avoid any pressure under the heel . ~ 6/16/17, .is able to slightly wiggle toes. Toes are swollen, warm to touch. Unable to palpate pulse due to swelling . 6/19/17, .Called .Orthopedics regarding resident's increased swelling and pain to her LLE (Left Lower Extremity) . Nursing notes continue. ~ 6/20/17, .Initiated fitting for modified w/c (wheel chair) to support L (left) foot in elevated position when up in w/c . This was 17 days after R1 fractured her ankle, 7 days after R1 developed an unstageable pressure injury, and after the facility identified increased swelling of R1's left foot. Increased swelling increases pressure within a hard surface. This in turn increases the pressure to R1's pressure injury as identified on 6/13/17 potentially causing further destruction of the wound and surrounding skin. Nursing notes continue. ~ 6/27/17, .returned from Ortho appointments with the following progress note: .4x4 cm (4.0 centimeters by 4.0 centimeter) dry, stable dark eschar with no surrounding [DIAGNOSES REDACTED] or drainage .new cast applied .Keep pressure off heel .use pillow to support calf . On 7/25/17 R1 was seen in the orthopedic clinic. A physician's progress note dated 7/25/17 indicated a walking boot was placed. The physician also ordered a wound clinic consult. Nursing notes continue. ~ 7/25/17, .Left heel pressure sore assessed .left heel 4x5cm (4.0 cm by 5.0 cm) black hard eschar tissue. To the left of sore 1.7x0.3cm (1.7 cm by 0.3 cm) are of red moist tissue . The nursing note dated 7/25/17 was the first assessment completed by the facility. On 7/25/17 at 10:55 a.m. Surveyor observed R1 seated in her room next to her bed. R1 had bilateral leg rests which were extended approximately 45 degrees. There was no pillow under R1's left leg. On 7/25/17 at 5:25 p.m. Surveyor observed R1 seated at a dining room table. R1's leg rests were elevated approximately 45 degrees. There was no pillow under R1's left leg. On 7/26/17 at 7:35 a.m. Surveyor observed R1's left heel pressure injury with RN-C (Registered Nurse) and LPN-D (Licensed Practical Nurse). Surveyor noted a large black red area of eschar on the back of R1's heel measuring per RN-C at 4.0 cm (centimeters) by 5.0 cm. On the left upper side of the wound was an area measuring approximately 1.0 cm where the eschar was pulling away from the skin. RN-C indicated there had been a scant amount of drainage from the area. R1 indicated the wound was painful.

Based on observation, interview, and record review, the facility did not ensure 2 of 6 residents reviewed for falls (R1, and R3) were afforded the necessary care to ensure an accident free environment. Example 1 R1 had a witnessed fall in the bathroom during a transfer. The CNA assisting R1 was aware R1 required a two person assist but did not follow R1's plan of care and transferred R1 by himself. R1 fell and sustained 3 fractures of the bone structures of the lower leg. R1 subsequently suffered from pain, developed a pressure injury, and had a decline in overall functioning. Example 2 Fall interventions implemented and updated on the care plan after R3 sustained a fall were not followed, which resulted in R3 sustaining another fall. Care plan was also not updated to include additional toileting schedule interventions. Findings. Surveyor completed a review of R1's clinical record and noted the following. R1 had current [DIAGNOSES REDACTED]. R1's MDS dated [DATE] indicated R1 required extensive assistance of one or two or more staff persons for all aspects of care, walked with the assistance of 2, had no falls, had no indicators of pain, and had no pressure injuries. R1 fall care plan was dated 10/20/16. The care plan had the following approaches. ~ 10/20/16, .verbal reminders not to ambulate/transfer without assistance .Keep personal items and frequently used items within reach .Monitor for visual hazards .well-maintained footwear .environment free of clutter . ~5/31/17, fall intervention, care plan updated to two staff persons to transfer ~ 6/4/17, .Transfer resident 2 assist and Hoyer pending therapy evaluation . Surveyor completed a review of R1's nursing notes and noted the following. ~ According to a nursing, on 5/31/17, R1 had a witnessed non-injury fall in the bathroom. The nursing note indicated staff were assisting R1 to transfer onto the toilet when R1 stood up impulsively, lost her balance causing staff to lower R1 to the floor. According to the facility's investigation R1 stood up without staff being ready to transfer R1. Staff subsequently lowered R1 to the floor. The facility changed R1's plan of care to include two staff persons were to transfer R1 at all times. ~ According to a nursing note on 6/3/17 R1 had a witnessed fall in the bathroom. The nursing note indicated R1 was lowered to the floor when R1's leg gave out during the transfer. According to the facility's investigation CNA-F attempted to transfer R1 without a second person to assist. The investigation indicated during the transfer R1 lost her balance and fell to floor with her left leg twisted under her. The investigation indicated CNA-F was aware R1's plan of care had changed after the fall on 5/31/17 from a one person transfer to a two person transfer. The investigation indicated CNA-F forgot R1 required two assistance. R1 subsequently sustained 3 fractures of the most distal (closest to the ankle) fibula. Surveyor completed a review of R1's hospital records dated 6/4/17. The reports indicated R1 had 3 separate fractures. Two fractures were noted on the most distal fibula. These were noted as mildly displaced (not in proper alignment). The third fracture was noted as comminuted (a bone broken into more than two fragments) fracture across the joint of the most distal fibula. Surveyor completed a review of R1's nursing notes and noted the following. ~ 6/12/17, .SCSA (Significant Change in Status Assessment) completed r/t (related to) fall with fx (fracture) and subsequent decline in function and cognition, and decline in continence. Currently Hoyer transfers . ~ 6/14/17, .Resident had a significant change to her status r/t recent fall with fx .Her activity participation is less since her fall .has been resting more . R1's most current MDS (Minimum Data Set) was dated 6/14/17 and reflected a change. The MDS was noted as a significant change in condition MDS. The MDS indicated R1 was cognitively intact, required extensive to total assistance of two or more staff persons for all aspects of care except eating, did not walk, had 1 non-injury fall and 1 major injury fall, could not maintain balance without staff support, had almost constant pain rated at 10 on a 0 to 10 pain scale, and had one unstageable pressure injury. On 7/25/17 at 3:15 p.m. Surveyor spoke with CNA-B. CNA-B indicated prior to beginning their shift and prior to completing any resident care they were to refer to their care plan to ensure there were no changes. CNA-B also indicated CNAs gave report to each other at the beginning of each shift utilizing every residents' care card. CNA-B stated they were to report to on-coming CNAs any changes in resident care. CNA-B also indicated at times changes were not noted on resident care cards at which point they referenced the facility's 24 hour shift to shift report. On 7/26/17 at 10:34 a.m. Surveyor spoke with RN-C (registered Nurse). RN-C indicated she was the nurse manager on the unit in which R1 resided. RN-C indicated she expected all staff to follow residents' care plans. Example #2 Surveyor completed a review of R3's clinical record and noted the following. R3 had current [DIAGNOSES REDACTED]. R3's most current MDS (Minimum Data Set) was dated 5/9/17 and noted as an admission MDS. The MDS indicated R3 required extensive assistance of 2 or more staff persons for all aspects of care including eating, had a fall history, and R3's could not maintain balance without staff assistance. R3's fall care plan was dated 5/5/17. The care plan had the following approaches. ~ 5/5/17, .verbal reminders not to ambulate/transfer without assistance .toileting scheduled every 2 - 4 hours .Transfer resident with 2 staff . ~ 5/15/17, .Keep bed in lowest position .mat at bedside .Keep personal items and frequently used items within reach . ~ 5/20/17, .Call don't fall sign in room and bathroom .Pressure alarm in wheelchair . Surveyor completed a review of R3's nursing notes and noted the following. ~ According to a nursing note dated 5/20/17, R3 had a non-injury fall in the bathroom. The facility's investigation indicated R3 was attempting to go to the bathroom and R3 missed the chair when attempting to sit. The facility changed R3's care plan to include a pressure alarm in the wheel chair to alert staff of R3's independent transfers. ~ According to a nursing note dated 5/22/17, R3 had a non-injury fall in the bathroom. According to the facility's investigation the alarm on R3's wheel chair had not been turned on. The investigation also indicated R3 had been incontinent of urine. The facility implemented an every two hours toileting schedule. R3's care plan had not been followed. The alarm placed in R3's wheel chair after a fall two days prior was not on. Additionally the intervention to assist R3 to the bathroom every two hours was not added to R3's plan of care. On 7/25/17 at 3:15 p.m. Surveyor spoke with CNA-B. CNA-B indicated prior to beginning their shift and prior to completing any resident care they were to refer to their care plan to ensure there were no changes. CNA-B also indicated CNA's gave report to each other at the beginning of each shift utilizing every residents care card. CNA-B stated they were to report to on-coming CNA's any changes in resident care. CNA-B also indicated at times changes were not noted on resident care cards at which point they referenced the facility's 24 hour shift to shift report. On 7/25/17 at 3:12 p.m. Surveyor spoke with LPN-A (Licensed Practical Nurse). LPN-A indicated all nurses were responsible begin a fall investigation to determine the root cause of the fall. LPN-A indicated the nurses were also responsible to update resident care plans to include new fall interventions. LPN-A indicated the fall report and investigation were reviewed by the DON (Director of Nursing) to ensure fall interventions were appropriate. On 7/26/17 at 10:34 a.m. Surveyor spoke with RN-C (registered Nurse). RN-C indicated she expected all staff to follow residents care plans.

Based on observation, resident and staff interviews and record review the facility did not prevent a fall and thoroughly invest the circumstances of the fall for 1 of 12 residents reviewed for falls. R16 slid out of the sit to stand lift sling during a transfer with 1 staff rather than 2 staff as her care plan indicated. Prior to the nurse assessing her, staff rolled R16 onto a mechanical lift sling. R16 was found to have an acute fracture the humeral neck (top of the upper arm). This is evidenced by: R16 has [DIAGNOSES REDACTED]. The most recent Minimum Data Set Assessment ((MDS) dated [DATE] reveals that R16 is totally dependent on two staff for transfers. R16's Care Plan Update dated 12/15/16 indicates that R16 was an assist of 2 with the Stand Lift. A copy of this update was given to Surveyor from PT-F (Physical Therapist). On 01/23/17 at 6:40 a.m., Surveyor observed R16 in her wheelchair in her room. R16 had her right arm in a cloth sling. Surveyor asked R16 why her arm was in a sling. R16 indicated that she hurt her arm. R16 told Surveyor that she had went to the bathroom and 1 person was with her and she was standing and slid and hurt her arm. R16's Nurse's Progress Notes dated 12/28/16 at 9:40 a.m. states, Writer called to room by CNA (Certified Nursing Assistant) at 0915 (9:15 a.m.). Resident was on floor outside of bathroom. CNA stated resident was being transferred from STS (Sit to Stand lift) to wheelchair when resident lifted arms and started to slip out of sling. Resident made it into wheelchair, then slid slowly to floor. Resident did not hit head. Assessment done by writer and Charge RN (Registered Nurse). Resident denied pain. No injury noted. Red area on R (right) medial lower bicep. ROM (range of motion) per norm. VSS. Resident requested to lie down. Will continue to monitor. A second note on 12/28/16 at 12:00 (noon) indicates the following: Resident c/o (complained of) increased pain to R arm with movement after being brought to dining room for lunch. Stated needing a sling for the arm. Given PRN APAP (as needed acetaminophin), and arm elevated on pillow. Will continue to monitor. Another note on 12/28/16 at 17:54 (5:54 p.m.) says: Xray impressions: R humerous-1. acute comminuted impacted transverse fracture of the R humeral neck. The right humerous is otherwise intact. 2. Severe primary osteoarthritis of the right glenohumeral joint. Mild primary osteoarthritis of the right acromioclavicular joint. Review of the fall investigation tool for R16's 12/28/16 fall states, .12. Was the care card (care plan) being followed: No if not, why? Resident STS 2 assist. 1 CNA transferring resident at time of fall .17. Staff Statements: Resident was on toilet took her off she was fine. Stood up got w/c under her and she pulled her arms out of sling to STS. Got w/c close enough and she let go and was lowered to the floor. Did not hit her head. Signed CNA-A (Certified Nursing Assistant). 18: Staff Statements: Resident .stood well getting on the toilet. Signed CNA-C . An employee corrective action report dated 12/28/16 indicates the following under description of problem or situation and policy violated: Did not follow transfer technique indicated on care card for resident resulting in resident slipping to floor during STS transfer. Resident was being moved before nurse entered to perform assessment following fall. Resolution or Corrective action to be taken: Follow care cards as instructed-as is critical part of your job-follow policy for not moving resident after fall until directed by supervisor .An additional note on the bottom of this form indicates the following: CNA transferred resident with STS alone-care card indicates transfer needs to be STS assist of 2. Report to floor nurse was that before going in room care card stated 1-2 assist and new care card showed 2 assist. Transfer status changed on 12/15/16 from hoyer lift to STS which is already indicated on all care cards dated 12/16/16 to present. When nurse arrived in room to assess resident resident was on floor on her back and the hoyer sling was underneath her-an additional 2 CNA's were present at this time. On 01/23/17 at 9:00 a.m., Surveyor spoke with CNA-A. CNA-A indicated CNA-C had helped her assist R16 to the bathroom with the sit to stand lift. CNA-A indicated that R16 wanted to go lay down. CNA-A said that CNA-C was busy so she assisted R16 to a standing position alone with the sit to stand lift off the toilet and was wheeling R16 out of the bathroom. CNA-A stated R16 was at the edge of her wheelchair when she put her hands up and pulled them out of the sling. CBA-A indicated R16 had her feet on the STS and came totally out of the sling and went to the right down to the floor. CNA-A indicated R16 hurt her right shoulder. A said the ADON (Assistant Director of Nursing) had spoken to her about this incident for not following the care plan to use 2 staff with transfers. On 01/23/17 at 1:40 p.m., Surveyor spoke with PT-F. PT-F indicated R16 had been a Hoyer Lift transfer and R16 and her family wanted to try to use the sit to stand lift so physical therapy had picked R16 to work on this. PT-F said that they switched R16 to a sit to stand transfer with 2 staff in mid December 2016. PT-F said they had communicated this change from the Hoyer Lift to the sit to stand with 2 assist to staff on R16's living area. On 01/23/17 at 3:30 p.m., Surveyor spoke with the Assistant Director of Nursing (ADON). The ADON indicated she had completed the investigation on R16's fall on 12/28/16 with the sit to stand. The ADON said CNA-A had assisted R16 off the toilet with the sit to stand by herself rather than getting help from a second staff person. The ADON said there should been 2 staff assistance with the transfer. The ADON indicated that when the nurse had come into the room to assess R16, staff had already put a Hoyer sling underneath R16 and they should not have moved R16. The ADON concluded that R16's fall using the sit to stand could have been avoided if 2 staff would have been assisting R16 with the transfer. On 01/24/17 at 7:20 a.m., Surveyor spoke a second time to the ADON. The ADON indicated that CNA-B and CNA-C were in the room when the nurse went to assess R16 after her fall using the sit to stand. The ADON was asked if she got statements from CNA-B and CNA-C. The ADON said that if she did, she did not write them down. On 01/24/17 at 7:45 a.m., Surveyor spoke with the NHA (Nursing Home Administrator). Surveyor asked the NHA for evidence that other staff and R16 were interviewed about the fall and staff putting the hoyer sling underneath R16 before the nurse came to assess. No additional information was received related to the requested information. On 01/24/17 at 8:25 a.m., Surveyor spoke a second time to CNA-A. CNA-A said once she got CNA-C into the room after R16's fall, they had rolled R16 onto the Hoyer sling before the nurse came into the room. On 01/24/17 at 8:50 a.m., Surveyor spoke with CNA-C. CNA-C said she helped CNA-A get R16 onto the toilet using the STS on 12/28/16. CNA-C said she was in the dining room when CNA-A came into the dining room and told her R16 had fallen onto the floor. CNA-C said when she got in R16's room R16 was on the floor. She did not see the sit to stand sling, the sit to stand lift was pulled back, and she was not sure where R16's wheelchair was. CNA-C said CNA-A then went to get the nurse. CNA-C said CNA-A came back and they put a pillow underneath R16's head and CNA-A said to put the Hoyer sling underneath R16. CNA-C said that R16 had told them that her right arm hurt.

Based on observations, staff interviews and record reviews the facility did not ensure appropriate supervision of 1 of 16 sampled residents. Resident #6 has had 18 documented abusive encounters with Residents #1, #9, #10, #13, #14, #15, #16, and other unidentified residents. Despite staff knowledge of Resident #6's increasing behaviors and knowledge that he singled out certain peers, the facility did not implement approaches to keep other residents safe. This caused residents to be upset, to cry, to be agitated and to feel uncomfortable when Resident #6 was around. This is evidenced by: Resident #6 was admitted to the facility on [DATE] with a progressive neurological disorder. Review of Resident #6's most recent annual Minimum Data Set Assessment ((MDS) dated [DATE] reveals the following: ~Brief Interview of Mental Status (BIMS) score of 15/15. ~Wandering daily. ~Walks and transfers independently in room. ~Walks in corridor with supervision. ~[MEDICAL CONDITION]. Resident #6's care plan includes a problem dated 1/3/13 of "Resident has socially inappropriate/disruptive behavioral symptoms as evidenced by physical advances towards female staff members..." The approaches include, "Encourage visiting family member to hug, kiss, and hold the resident's hand. Monitor and document behaviors. When behavior occurs, explain immediately why behavior is inappropriate." The care plan also includes a problem dated 12/7/12 of "Alteration in mood. Verbally abusive behavior..." Approaches include, "Assess for pain or s/sx (signs and symptoms) of infection. Ask resident what is wrong and allow him to express his feelings...Ask social services to intervene, if necessary. Document effectiveness of interventions. Medicate with PRN (as needed)..." Review of Resident #6's progress notes (indicated with a ~) reveals the following entries: ~"05/30/13 2:38 a.m., Writer informed by CNA...that while she was in a female resident's room performing personal cares, Resident #6 entered the room. When CNA told him he had to leave, Resident #6 then approached CNA standing very close to her. CNA again very firmly told Resident #6 that he had to leave and walked forward until resident backed up and out of room. When Resident #6 came down hall back towards nursing station this writer informed him that he cannot go into other resident's rooms; when he is awake at night he may be in his room or the lounges adjacent to the dining rooms but is not to enter other resident's rooms. Resident #6 then indicated the CNA was his friend and turned to go back down hall. When writer questioned where he was going, he said, "to harass (CNA)" Writer indicated he should not do that and had to say resident's name several times to get him to stop walking, whereupon resident went into lounge and sat on the couch. In speaking to other nurse on shift, she indicated that Resident #6 had approached a resident on her wing who was up in a wheelchair and told her that 'You look stupid in that chair. Resident #6 was redirected away from resident..." During an interview on 9/23/13 at 11:25 a.m., the NHA (Nursing Home Administrator) later identified the peer as a resident who is not listed on the SOD Identifier Key. On 6/5/13, Resident #6's care plan for "Alteration in mood" was update with the approaches of, "Allow time for resident responses...Convey acceptance of resident with interactions. Give reminders on appropriate language and content for conversations. Praise for his positive interactions...Redirect if verbalizing negative or inappropriate statement to staff or peers." ~"07/16/13 5:22 a.m. This writer informed by CNA she had seen resident enter and then quickly leave Resident #10's room. Two females are residents of this room. I stood at end of hall and observed resident come out of his room and move to enter Resident #10's room. When I called resident's name, he paused, looked at me and continued into Resident #10's room. When I approached and called him again, he came back out. I explained to resident he cannot go into other resident's rooms and that at night he is to either be in his room or one of the public lounge areas. When asked why he was entering Resident #10's room, he stated "To give her a hard time." I explained this was inappropriate and not to do it. Resident did not respond and simply walked away, went into the north lounge and laid down on the couch....Will refer to Social Services." ~"07/18/13 9:37 p.m. Resident had one episode of agitating another resident but was redirected and there were no further behavior problems this shift...." ~"07/21/13 5:45 a.m. Resident was seen entering Resident #10's room x 1. Was immediately redirected out and he did leave without resistance." ~"07/28/13 11:39 a.m. Resident #1 was attempting to leave the dining room with a 1:1 staff member and they began walking towards the 400 wing. Resident (#6) got up and walked over stood in front of res. Res (#6) stood face to face with her in an aggressive manner. Staff member asked res (#6) to move out of the way, and res (#6) stated to 'buzz off' to the staff member, Resident #1 told him (Resident #6) to 'get the hell away from me,' res then moved closer to Resident #1. Staff member stepped in between the two res to prevent any physical confrontation. Writer then approached res (#6) and Resident #1 and assisted between the two of them, and asked him not to be approaching res in an aggressive manner and to please leave the area. Res (#6) then turned to writer and within 2 inches of writers face, he repeatedly told writer to 'buzz off' res then walked to lounge area. Resident #1 then started walking away again and res (#6) then quickly re-approached res (#1)from behind stating 'she is going down by my room.' Res (#6) continued to follow behind res (#1) while on the unit." On 7/29/13, Resident #6's care plan was update to include an approach of "Provide increased monitoring/supervision as needed to intervene if any verbal aggression, disruption." ~"08/04/13 9:22 p.m., has again shown pacing behaviors before during and after supper; needed cuing to move away from two ladies who began to cry when he approached multiple times-resident is now in bed and sleeping." Staff did not identify of the 2 female peers referenced in this entry. ~"08/06/13 9:36 p.m. resident approached a female resident in the dining room times four tonight; he was redirected each time by staff and he did leave resident's side returning after a few minutes-after supper he did return to his room and has been in room since." Staff did not identify the female peer referenced in this entry. ~"08/15/13 2:40 p.m., Resident was standing next to another resident at the nurses station. Resident was asked by staff if he needed anything and he stated no. He was asked to back away from other resident which he did but stepped next to her again. Staff once again asked him to step away from the other resident and to give her some space but he refused and stated, 'She is always in my room irritating me so I am going to stand here and irritate her.' Staff intervened and separated residents. Writer has not observed the resident he was talking about to be in his room. Nursing and social services notified..." Staff did not identify the female peer referenced in this entry. ~"08/16/13 6:28 p.m. Resident had been increasingly 'bothering' other resident and some staff and visitors...Resident then was removing the clip alarm of another resident so that the alarm would sound. Staff would respond to the alarm only to find resident holding the sounding alarm and taunting the other resident... Staff did not identify the peer referenced in this entry. ~"08/17/13 12:20 p.m. Resident's restlessness continues at lunch time. Resident approaching other residents, and singling out one resident in particular who got very upset. Attempted to re-direct resident multiple times unsuccessfully. Resident eventually went back to own room and laid down on the bed and listened to music..." Staff did not identify the peer referenced in this entry. ~08/17/13 3:06 p.m. Resident has been redirected by multiple staff members as he is continually trying to push another residents wheelchair and standing so close to the other resident that he is touching her wheelchair. She is becoming upset and continues to tell him to get away from her. Staff continues to remove the other resident away from him and redirect him to an activity unsuccessfully. Staff assuring that the other resident is safe and is continuing to monitor the situation." Staff did not identify the peers referenced in this entry. ~"08/17/13 3:11 p.m. Resident is seeking out female resident and standing so close to her that she is unable to maneuver her w/c (wheelchair) around him. He has made attempts to push her in her w/c. Staff has asked resident to go his own way and to leave the other resident but he refused and stated, 'Nope it's a free country.' Female resident was brought behind the nurse's station by writer to separate the two..." During an interview on 9/23/13 at 11:25 a.m., the NHA later identified the other resident as Resident #13. ~"08/17/13 3:13 p.m. Resident very restless, repeatedly reapproaching a few female residents, getting into other's spaces and yelling at them, verbalizing loudly, turning off televisions, refusing to be redirected to room and other areas...on call manager/SW called and she will be in..." ~"08/19/13 10:45 a.m., ...restless pacing redirected >15 times to move away from female residents just prior to breakfast..." Staff did not identify the peers referenced in this entry. ~"08/23/13 9:52 a.m., this morning res was wheeling res... in the south lounge fast, and res legs were bouncing up and down almost coming into contact with the carpet. Writer asked res to leave the other res there and that we would get her to the dining room for her meal on time (prior to this res...was in the lounge watching out the window). res looked at writer in an angry way and pushed res...forward fast and let her go. Res went about 7 feet before writer was able to stop res from the forward propelling. Writer asked res not to do that again and explained it is not safe for any res to be just pushed like that. res approached writer and gave writer an angry look for several seconds, and asked res to please have a seat in the lounge or dining room, and res did leave the area at this time, no further issues noted." During an interview on 9/23/13 at 11:25 a.m., the NHA later identified the other resident as Resident #14. ~"08/28/13 11:14 p.m. Resident kept appointment with Dr...and returned. Resident had no behavior problems during transport to and from MD visit. Resident had no behavior problems this shift. Progress notes states, "Disease related behavioral problems, will attempt higher aripiprazole but unlikely to correct behaviors. Needs constant supervision. Order received to increase Aripirpazole ([MEDICATION NAME]) 5 mg take 1 tablet by mouth twice daily." Despite the documentation of the above behaviors and the physician's evaluation that the medication increase was unlikely to improve the behaviors, the facility did not assess Resident #6's behaviors and develop a care plan to address the ongoing concerns of seeking out particular residents and causing them distress. ~"09/03/13 1:33 am Note for 09/01/13, resident was noted to be pacing on and off throughout this shift...he has been quiet although does approach some residents, especially females and stands behind them staring at them but saying nothing..." Staff did not identify the peers referenced in this entry. ~"09/21/13 9:21 a.m...monitoring continues, 1:1 provided for brief periods..." ~"09/21/13 10:36 p.m. Resident has been very disruptive and having major behavioral problems. Resident was wandering about facility and was not redirectable...When resident was laving the dining area he did slap another resident on the right shoulder in an aggressive manner. The resident he slapped was his roommate (Resident #9). Residents roommate was examined and no injury or c/o pain was found and roommate was moved into another room for safety... On 9/22/13, Resident #6 was removed from the facility by police officers due to escalation in behaviors. Surveyor # review of Resident #6's most recent care plan received from the facility on 09/21/13, pages 1-8 do not have specific goals and approaches addressing Resident #6's behaviors of going into female resident rooms and invading the personal space of facility residents, following facility rules, and coping with his disease process. On 09/22/13 at 7:20 a.m., Surveyor # spoke with RN-E (Registered Nurse). RN-E indicated that Resident #6 had been taken out of the facility by the police department in morning hours. RN-E indicated that Resident #6 had become physically and verbally aggressive to staff on the p.m./night shift after taking and opening mail that had belonged to other residents. RN-E said that Resident #6 had also hit his roommate. RN-E said that Resident #6 resisted the police and was restrained prior to leaving. Surveyor # spoke a second time with RN-E at 1:15 p.m. RN-E indicated that Resident #6 has become increasingly restless and pacing, invading the space of residents and staff. RN-E indicated that Resident #6 had not been physically aggressive to other residents until 09/21/13, when he slapped his roommate on the back. RN-E indicated that Resident #6 has become more difficult to redirect. RN-E indicated that Resident #6 would invade the space of two residents in particular; Resident #10 and Resident #15. On 09/22/13 at 10:40 a.m., Surveyor # observed Resident #6 back at the facility. Resident #6 was with staff sitting at a table playing cards. Resident #6 was observed to have rug burn type abrasions to his cheeks and his legs. On 09/23/13 at 6:10 a.m., Surveyor # spoke with RN-B. RN-B indicated that Resident #6 is up almost all night for the last couple of weeks. RN-B indicated that Resident #6 has been putting numerous letters on the receptionist's desk in the front lobby. RN-B said that Resident #6 will lay on the sofa in the lounge and that Resident #6's roommate can be loud at night and talks to himself all night long. RN-B said that when Resident #6 is up at night the night staff have to watch him very closely because he will go into other residents' rooms. RN-B indicated that Resident #6 would purposefully annoy Residents #10 and #15, so they were moved to different wings of the facility. RN-B indicated that she thinks that Resident #6 is bored and that he pushes the limits with staff. RN-B said that Resident #6 seems to focus on Residents #10, #15, and #16. RN-B said that Resident #10 has cried, has been agitated and appears uncomfortable when Resident #6 is around her. RN-B said that the mail for the residents come to the front desk in the lobby and is put on the counter. RN-B said that a firm approach works best and telling Resident #6 "no," when he is attempting to do things that he should not be doing. On 09/23/13 at 8:45 a.m., Surveyor # spoke with CNA-A. CNA-A indicated that Resident #6 will come into the dining room and stand very closely to Resident #10. CNA-A said that Resident #6 has also had similar problems with Resident #13 a few months ago. CNA-A indicated that lately Resident #6 has been more difficult to redirect and has become more verbally aggressive to staff in response to redirection. On 09/23/13 at 9:05 a.m., Surveyor # spoke with CNA-C (Certified Nursing Assistant). CNA-C indicated that Resident #6 invades the space and stands close to female residents. CNA-C indicated that Resident #6 will follow people around. CNA-C said that Resident #6 focuses on Resident #10 and will stand next to her very close and Resident #10 will get agitated when Resident #10 does this. On 09/23/13 at 9:35 a.m., Surveyor # spoke with CNA-F. CNA-F indicated that Resident #6 has been increasing with his pacing, wandering into other resident rooms, invading the space of other residents. CNA-F indicated that Resident #6 doesn't seem to recognize personal space and will stand very close. CNA-F said Resident #6 would repeatedly stand in the space of Resident #10. On 09/23/13 at 10:35 a.m., Surveyor # spoke with SW-D (Social Worker). SW-D indicated that Resident #6 has become increasingly agitated, has had issues with personal space, particularly with Resident #10. SW-D indicated that Resident #6 must have taken the resident mail off of the counter in the front lobby before staff could get it. On 09/23/13 at 11:25 a.m., the NHA indicated that a meeting is scheduled for 2:00 p.m. on 09/23/13 with Resident #6's wife/power of attorney for health care, the Medical Director of the facility, and Management staff to discuss the incident involving Resident #6 on 09/21/13 and 09/22/13.

Based on observations, interviews, and record reviews, the facility did not implement an infection control program in order to prevent transmission during an outbreak of gastrointestinal disease/infection. The facility had 53 residents at the start of the survey on 12/6/10. During initial tour of the facility, the survey team identified 2 residents who were ill with gastrointestinal symptoms of nausea, vomiting, and diarrhea. By the end of the day, 2 staff and 6 residents were ill on 2 units. On 12/7/10, 4 additional staff and 9 residents on 3 units were ill with gastrointestinal symptoms. On 12/8/10, 8 additional staff were ill and 18 residents were ill with gastrointestinal symptoms. Observations throughout the dates of survey found that: 1. Staff did not use appropriate precautions/protective personal equipment when caring for ill residents; 2. Ill residents were not always separated from those residents who were not ill to reduce the risk of transmission; 3. Nursing, activity, therapy, and housekeeping staff were allowed to work on all units and were not confined to one unit; 4. Housekeeping did not ensure proper concentration of cleaning solution; 5. Housekeeping used the same water, rags, and mop heads to clean multiple rooms; 6. Housekeeping did not initiate more intensive cleaning procedures including cleaning of high touch areas; 7. The facility continued to admit residents; 8. Employees were not aware of how long they needed to remain off of work after an illness; and 9. The facility did not maintain accurate line listing of staff who called in sick. These failures had the potential to affect all 53 residents of the facility. The facility's failure to immediately implement appropriate procedures to limit the transmission of disease - which can be particularly serious for individuals with compromised conditions or multiple co-morbidities - created a situation of Immediate Jeopardy. This began on 12/06/10 when the facility first identified a potential outbreak of gastrointestinal disease. The facility was notified of the finding of Immediate Jeopardy on 12/9/10. The Immediate Jeopardy was removed on 12/13/10 when the facility: 1. Educated all staff including Nursing, Therapy, Activity, Food Service, and Houskeeping/Laundry: ~On the signs/symptoms of GI infection; ~Hand washing; ~Appropriate isolation precautions including when and how to implement; ~Quarantining ill residents to their rooms; and, ~Excluding ill staff from working with residents and their ability to return to work. 2. Developed procedure for notifying staff of resident illness and need for isolation precautions. 3. Stopped new admissions. 4. Began auditing staff knowledge and implementation of policies and procedures for all departments. 5. Made Personal Protective Equipment available outside each ill residents' room. 6. Increased the frequency of environmental cleaning. 7. Implemented enhanced environmental cleaning until 72 hours after last documented case. The deficient practice continues at a scope/severity level of an F (potential for harm that is not immediate jeopardy/widespread). The facility still needs to fully operationalize their policies and procedures, complete education of staff, and address inconsistencies and lacking information in tracking and trending of resident and staff illnesses.

Based on record review, policy review, and interviews, the facility did not ensure that 2 of 4 sampled residents were provided sufficient fluid intake to maintain proper hydration and health. Resident #3 was admitted with several diagnoses, lab values, and medications that demonstrated she is at a very high risk for dehydration. There is no evidence that the facility assessed her immediate needs related to hydration or implemented a care plan to address this problem. After 6 days in the facility, Resident #3 was hospitalized for [REDACTED]. Resident #4 was admitted to the facility with a [DIAGNOSES REDACTED]. Assessments that were completed related to nutrition and hydration, did not contain accurate information. Although "Dehydration" triggered as a problem area on the RAPs, the facility did not evaluate all documented risk factors and did not develop a care plan to address this problem. This is evidenced by: On 11/15/10, the facility provided Surveyor # a copy of the policy titled "Admission of Resident (Procedure for Day Of)." Noted in the policy was Item #VIII, Dietary staff will complete an initial nutritional interview. Surveyor # requested a copy of the facility's policy and procedure related to assessing hydration. The facility submitted a copy of the policy and procedure "Assessment Nutritional." Hydration is not addressed in the policy and procedure. Example #1: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Surveyor # reviewed the hospital records that were contained in Resident #3's medical record at the facility and noted the following: ~Resident #3 was initially admitted to the hospital on [DATE] following a fall. Resident #3 had surgical repair of her right [MEDICAL CONDITION] on 10/05/10. Following surgery, Resident #3 developed pneumonia and [MEDICAL CONDITION]. ~Resident #3 was transferred from the hospital to a skilled nursing swing bed unit on 10/15/10. The History and Physical dated 10/15/10, states that Resident #3 was originally admitted to the hospital for surgical repair of a [MEDICAL CONDITION]. Post operatively, Resident #3 experienced pneumonia and [MEDICAL CONDITION] "based on the fluid that she received during surgery." Resident #3 was receiving 40 mg (milligrams) of [MEDICATION NAME] (a diuretic) 2 times a day to eliminate the excess fluid. ~On 10/16/10, the physician added [MEDICATION NAME] 2.5 mg (also a diuretic) each day to Resident #3's medication regimen. ~Daily laboratory values while in the hospital include: *10/16/10: BUN-17 (Normal is 7-19), Creatinine-1.0 (Normal is 0.7-1.5), BUN/Creatinine Ratio-17.0 (Normal is 10-20) Sodium-138 (Normal is 133-143). *10/17/10: BUN-15, Creatinine-0.9, BUN/Creatinine Ratio-16.7, Sodium-138 *10/18/10: BUN-19 (High), Creatinine-1.1 (High), BUN/Creatinine Ratio-17.3, Sodium-137 *10/19/10: BUN-26, (High) Creatinine-0.9, BUN/Creatinine Ratio-21.7 (High), Sodium-138 Resident #3 had an activated POAHC (Power of Attorney for Health Care). The POAHC signed the advanced directives document on 10/19/10, which notes that artificial administration of nutrition or hydration would be considered. The advanced directive document was also signed by the physician on 10/20/10. The initial care plan completed on 10/20/10, instructs the nursing staff that Resident #3 needs partial to total assist with feeding. The Guidelines for Daily Care document completed on 10/20/10, notes Resident #3 has a history of aspiration and needs assistance with eating. The diet listed as regular, small portions with Ensure 8 ounces, three times per day with meals, and 1 scoop of ProMod with meals. Even though Resident #3 had lab values which could be indicative of a fluid imbalance, there is no evidence that a hydration assessment was completed to determine Resident #3's immediate needs related to hydration. Review of the physician orders [REDACTED]. Based on the facility's documented weight of 163-164#, Surveyor # calculated Resident #3's daily fluid needs to be approximately 1850 cc's (cubic centimeters) of fluids per day. This calculation considered Resident #3's cardiac and kidney diseases and used 25 cc's/kilogram. Review of the nursing notes revealed that Resident #3 had the following fluid intakes: *10/19/10 = Blank; *10/20/10 = 249 cc's; *10/21/10 = 600 cc's; *10/22/10 = 480 cc's; *10/23/10 = 300 cc's; *10/24/10 = 540 cc's. Resident #3's intake is 1601 cc's to 1250 cc's less than what is required for Resident #3 to maintain proper hydration and good health. There is no evidence of a hydration assessment being completed at this time, even though Resident #3's intakes are low. Lab values from 10/22/10 notes: BUN-61 High (normal for this laboratory is 7-23), Creatinine-1.54 High (normal for this laboratory is 0.46-1.44), and Sodium 140 (Normal for this laboratory is 133-145). These values have increased since Resident #3's admission to the facility. Documentation in the nursing notes on 10/22/10, identifies that the physician was informed of the marked increase in the above laboratory values. The physician continued with [MEDICATION NAME], but discontinued the [MEDICATION NAME] and requested that the labs be repeated on 10/25/10. Even though these values do not constitute a [DIAGNOSES REDACTED].#3's hydration status and fluid needs. The facility did not develop or implement care plan approaches to prevent dehydration for Resident #3. Lab values from 10/25/10 note: BUN-105 High, Creatinine-2.5 High, and Sodium-149 High. These values are significantly higher than previous values. On 10/25/10, Resident #3 was examined by the NP (Nurse Practitioner). The NP documented that Resident #3's tongue was coated with thick, white plaque, had dry mucous membranes and dry lips, had a respiratory rate of 44 (Resident #3's baseline 18-20), was mouth breathing, and had [MEDICAL CONDITION]. The NP assessment was "1. Acute [MEDICAL CONDITION], suspect dehydration in patient with poor intake. 2. ...possible pneumonia, she did have pneumonia in the hospital and this could have not resolved or recurred. 3. Oral thrush. 4. Mental status changes because of #1 and 2." The NP ordered for Resident #3 to be transferred to an acute care hospital. On 11/15/10, Surveyor # reviewed the complete medical record looking for hydration assessments, nutritional assessments, and evidence of facility interventions to meet Resident #3's hydration needs. No information was found. On 11/15/10 at 3:20 p.m., Surveyor # interviewed the RD (Registered Dietician) regarding Resident #3's nutritional assessment. The RD stated that she was unable to complete the nutritional assessment on the 10/19/10 (day of admission) due to Resident #3's lethargy. The RD stated she was out of the building on 10/20/10. The RD stated that on 10/21/10, she observed Resident #3 in the dining room at breakfast and questioned a CNA (Certified Nursing Assistant) about Resident #3's eating habits. The RD learned from the observation and information that Resident #3 should have Ensure added. The RD obtained that order from the physician on 10/20/10. The RD stated she observed Resident #3 again on 10/22/10, and again questioned a CNA about Resident #3's eating habits. The RD stated that she added ProMod (protein supplement) with each meal to promote wound healing on 10/22/10. The RD stated she did not interview Resident #3 or her family regarding likes and dislikes, and did not complete a nutritional or hydration assessment. On 10/25/10, the RD stated that Resident #3 was put on a trial puree diet due to reports of swallowing and choking problems. On 11/15/10 at 1:50 p.m., Surveyor # interviewed the DON (Director of Nurses) and the NHA (Nursing Home Administrator) regarding Resident #3's short nursing home stay. Surveyor # asked for any nutritional or hydration assessments, and care plans related to the same. The NHA stated she would look for additional information and provide that information to the Surveyor. On 11/15/10, the NHA provided a grievance report that noted on 11/02/10, the facility met with Resident #3's family. The NHA and the DON stated the family was satisfied with the medical information provided. The grievance report noted that family concerns were addressed. No assessments or care plans were provided. On 11/15/10 at 11:47 a.m., Surveyor # telephoned Family-A (Family member of Resident #3). Family-A stated Resident #3 was admitted to the hospital on [DATE], with severe kidney failure, dehydration, pneumonia, and a urinary tract infection. Family-A stated Resident #3 recovered and is currently doing well at another nursing home. Family-A stated that Resident #3 is currently able to communicate basic needs, is able to eat, and has returned to her previous level prior to the [MEDICAL CONDITION]. Example #2: Resident #4 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Upon admission, Resident #4 was receiving HCTZ ([MEDICATION NAME]) 25 mg for treatment of [REDACTED]. According to the Drug Information Hand Book for Nursing, HCTZ is a diuretic. It is used to treat hypertension and [MEDICAL CONDITION]. It causes a chemical change in the kidneys causing the kidneys to excrete increased water. Surveyor # requested Resident #4's I&O (intake and output) record. The DON (Director of Nursing) indicated that Resident #4 was never on I&O. The DON stated that fluids were documented by the CNAs (Certified Nursing Assistants) with each meal and snack. Surveyor # completed a review of Resident #4's medical record. The fluid intakes for each day were calculated by Surveyor # . The following was noted: ~7/29/10: Fluid intake of 240cc's. Weight is 153.1#. ~7/30/10: Fluid intake of 240cc's. Nurse's note, "...Hydration Findings: no s/s (signs or symptoms) of dehydration...Swallowing: states feels like food only goes part way down..." ~7/31/10: Fluid intake of 480cc's. ~8/1/10: Fluid intake of 1320cc's. Weight is 150.5# ~8/2/10: Fluid intake of 360cc's. Nurse's note, "...c/o (complained of) nausea, dry heaving...no emesis...continuous c/o (complaints of) nausea..." ~8/3/10: Fluid intake of 420cc's. Nurse's note, "...nausea and emesis...complained of nausea continuing..." ~8/4/10: Fluid intake of 120cc's. Nurse's note, "...complained of mild nausea...encourage food and fluid intake..." ~8/5/10: Fluid intake of 720cc's. Nurse's note, "...new complaint this am (morning) of burning with urination...UA (urinalysis) collected...urine dark yellow..." ~8/6/10: Fluid intake of 240cc's. Nurse's note, "started [MEDICATION NAME]([MEDICATION NAME]) for her uti (urinary tract infection)...Fluids have been encouraged...Nutrition: Very poor - Never eats full meal...fluids poor..." ~8/7/10: Fluid intake of 120cc's. ~8/8/10: Fluid intake of 360cc's. Weight is 149.3#. ~8/9/10: Fluid intake of 480cc's. On 8/9/10, an initial dietary assessment was completed. The assessment indicates that Resident #4 is at moderate risk for problems with fluid balance. The assessment indicates Resident #4 consumes 1,000 to 1499 cc of fluids per day and has no chewing or swallowing problems. The assessment also indicates that Resident #4 requires 1569 cc's of fluid per day which is based on Resident #4's ideal weigh of 115 pounds. The accuracy of the dietary assessment comes into question as noted: ~Resident #4's documented fluid intake ranged between 120 and 1320 cc's per day (assessment indicates 1000 to 1499 cc's). ~Resident #4's admission weight was 153.1 pounds. Recommended fluid intake based on Resident #4's admission weight would have been 2088 cc's per 24 hours. The assessment used Resident #4's ideal body weight (115#) and not actual body weight (153.1#) to calculate fluid needs. Resident #4's admission MDS (Minimum Data Set) dated 8/10/10, indicates Resident #4: ~Has no memory problems; ~Is independent in her decision making; ~Requires staff assistance for bathing, dressing, grooming, and toileting; ~Eats independently with setup help only; ~Has a wound infection; and, ~Has no indicators of problems with her fluid status. Resident #4's RAPS (Resident Assessment Protocol Summary) dated 8/10/10, triggered dehydration. The RAP summary indicated, "...triggered due to use of diuretic...HCTZ ([MEDICATION NAME])...will not proceed to care plan..." Surveyor # completed a review of Resident #4's care plan. It did not contain a problem regarding actual or potential problems with fluid balance. Under the problem titled "Potential for Weight loss" it indicates, "...Monitor weight weekly; Monitor food and fluid intake..." Despite Resident #4's risk factors for dehydration including low fluid intake, ongoing nausea/vomiting, possible infection, and continued diuretic use, the facility did not develop or implement a plan of care to assist Resident #4 in maintaining proper hydration. Documentation in the medical record continues: ~8/10/10: Fluid intake was 1320 cc's. Nurse's note indicates that the results of the urine culture were received and were not indicative of an infection. The antibiotic is discontinued and the physician order [REDACTED]. ~8/11/10: Fluid intake was 0 cc's. Nurse's note, "...has been NPO (nothing by mouth)...Res (Resident) is scheduled for a Gastroscopy this am...Pain...throat/esophogeal area, post gastroscopy...refused supper, but did take ice water..." ~8/12/10: Fluid intake was 360 cc's. Nurse's note, "...nausea vomiting...refused breakfast...dry heaving..." ~8/13/10: Fluid intake was 680 cc's; On 8/13/10, the facility completed a hydration assessment. This indicates Resident #4 usually consumed 50% to 75% of fluids offered and ate 50%-75% of meals. The assessment also indicates Resident #4 received a diuretic daily. The assessment also indicates that Resident #4 has no swallowing problems and has no symptoms of dehydration. The accuracy of the hydration assessment comes into question as follows: ~Review of Resident #4's meal intake records finds an average daily intake of approximately 29%. The assessment documents 50% to 75%. ~Resident #4's average daily fluid intake of 425 cc's, which is approximately 27% of her calculated fluid needs based on the facility's calculation of 1569 cc's (found in 8/9/10 assessment). The assessment indicates Resident #4 is receiving 50% to 75% of fluids. Documentation in the medical record continues: ~8/14/10: Fluid intake was 480 cc's. ~8/15/10: Fluid intake was 780 cc's. Weight was 148.8#. Nurse's note, "...complained of sudden nausea vomiting...continuing nausea..." ~8/16/10: Fluid intake was 940 cc's. ~8/17/10: Fluid intake was 580 cc's. Nurse's note, "...received order for additional suppository for nausea complaints..." ~8/18/10: Fluid intake was 580 cc's. On 8/18/10, a dietary note indicates that Resident #4's weight is decreasing, appetite is fair, and she is consuming 796 cc's of fluids per day. Despite Resident #4's continued complaints of nausea, intermittent emesis, intermittent refusals to eat and drink and weight loss, the facility did not implement changes in Resident #4's plan of care to direct staff on how to manage her fluid status. Documentation in the medical record continues: ~8/19/10: Fluid intake was 120 cc's (Resident documented as "out" for breakfast and lunch). Nurse's note, "...complained of anorexia..." ~8/20/10: Fluid intake was 660 cc's. Nurse's note, "...emesis this AM after breakfast...This has been ongoing..." ~8/21/10: Fluid intake was 360 cc's (no documentation for breakfast or supper). ~8/22/10: Fluid intake was 900 cc's. Weight was 143.2# This is a 9.9# weight loss in 25 days. ~8/23/10: No intake documented. ~8/24/10: Fluid intake was 120 cc's (no documentation for breakfast or supper). Nurse's note, "...Had emesis again this am..." ~8/25/10: Nurse's note, "...Refused [MEDICATION NAME] complaints of nausea, had emesis...refused to eat due to nausea...States 'I've never been so sick in my life'...Has had nausea at intervals since admission but has worsening in past days..." At Resident #4's request, she was sent to see her primary physician on 8/25/10. Resident #4 did not return to the facility. The facility was unaware of what Resident #4's disposition was. No additional information was received. Surveyor # completed a review of Resident #4's MAR (Medication Administration Record) and noted that Resident #4 received HCTZ on all days except 8/4/10 and 8/11/10. On 11/15/10 at 3:30 p.m., Surveyor # spoke with the DON and NHA (Nursing Home Administrator) regarding Resident #4. The DON indicated that Resident #4 had been admitted to the facility for rehab. The DON indicated that Resident #4 had ongoing problems with nausea and vomiting of unknown etiology. The DON also stated that Resident #4 has been seen by several practitioners regarding this. Surveyor # asked the DON how they monitored Resident #4's fluid status. The DON stated they had never done I&O for Resident #4. The DON stated the CNAs document fluid intake for meals and snacks. Surveyor # asked the DON when the CNA's documentation on intake was reviewed. The DON indicated the dietician reviews the documentation as well as the MDSC (Minimum Data Set Coordinator) during quarterly MDS reviews. Surveyor # asked the DON what the outcome was of Resident #4's clinic appointment on 8/25/10. The DON stated that Resident #4 never returned to the facility. The DON and NHA indicated they thought Resident #4 had been hospitalized but were uncertain. Review of MDS submissions found that Resident #4 had been admitted to a different nursing home. Review of the medical records found that after leaving Lillian Kerr, Resident #4 was admitted to an area hospital. The History and Physical report indicates that Resident #4 was admitted to the hospital on [DATE] for, "Acute urinary tract infection...dehydration secondary to nausea and vomiting... The patient will be admitted to the floor. Will start her on IV fluid resuscitation..."

Based on policy review, record reviews and interviews, the facility did not ensure that 6 of 9 sampled residents reviewed for incontinence received care and services designed to restore as much bladder function as possible. Resident #6, #7, and #14 had declines in bladder function. The facility did not assess the cause of the declines in bladder function, did not monitor the residents' usual voiding patterns, did not identify the types of incontinence, and did not explore reversible causes of incontinence in order to assist each resident with restoring or maintaining as much bladder function as possible. For Resident #8, #5, and #15, the facility did not comprehensively assess the residents' usual voiding patterns, determine the types of incontinence, develop care plans to improve bladder function, and explore reversible causes of incontinence. This is evidenced by: According to WOCN (Wound Ostomy and Continence Nurses Society), reversible causes of incontinence include: [MEDICAL CONDITION], infection, medications, bladder irritants, vaginitis, pharmaceuticals, polyuria, retention, constipation, environmental barriers, and physical limitations. Assessment of these factors is needed to determine a plan of care that could include bladder retraining, prompted voiding, and individualized scheduled toileting. This individualized schedule should be used rather than the facility's incontinence management toileting schedule currently being used for all cognitively impaired and incontinent residents who are unable to communicate with staff that they have to go to the bathroom. The outcome of incontinence services can be determined by recognition of the problem, nursing assessment, and referral for diagnostic evaluation and treatment. All residents with incontinence should be evaluated for causative factors, as treatment is dependent on these factors. However, before successful treatments can be initiated, the problem needs to be identified. The identifying of the type of incontinence is essential in a multidisciplinary collaboration for both the assessment of the individual and the treatment of [REDACTED]. The goal should be to restore as much normal bladder function as possible for each resident by decreasing or eliminating the incontinent episodes. This promotes dignity, reduces risk factors for skin breakdown, and reduces the incidents of urinary tract infections. On 12/08/10, the facility provided Surveyor # with the policy titled "Urinary Continence and Incontinence." The policy statements were: 1. The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. 2. Management of incontinence will follow relevant clinical guidelines. 3. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. The policy interpretation and implementation noted that the facility will observe and review relevant information, periodically (quarterly and with noted change in continence) define levels of incontinence, review details related to continence, identify risk factors for incontinence, review medications that may impact incontinence, identify types of incontinence, initiate toileting plans, and document results of toileting plans. On 12/08/10 at 12:40 p.m., Surveyor # interviewed the DON (Director of Nurses) and the NHA (Nursing Home Administrator) regarding the bladder incontinence program in place. The DON stated that the facility was owned by the Aspirus corporation up until 11/01/10, at which time it was owned by the Rennes corporation. The DON stated that during the Aspirus ownership, the facility did not identify types of incontinence. The NHA stated that in August 2010, the facility recognized a problem with incontinence care and began completing "bladder diaries" on all residents. The NHA stated the process stopped at that time due to multiple higher priority events including the change in ownership. Example #1: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility completed a quarterly bladder assessment on 04/07/09 which noted that Resident #6 had stress incontinence and with prompted voiding, would stay continent during waking hours. The facility completed an annual MDS (Minimum Data Set) for Resident #6 on 10/13/09 and noted the following: *short term and long term memory deficits; *moderately impaired daily decision making skills; *requires limited assistance with toilet use; *occasionally (2 or more times per week, but not daily) incontinent of urine; and, *on a scheduled toilet plan. Review of the urinary incontinence RAP (Resident Assessment Protocol) completed on 10/13/09, notes cognitive deficits and lack of awareness of need to urinate as problems. The RAP did not identify any patterns of incontinence or any type of incontinence. The facility completed quarterly MDSs for Resident #6 on 04/13/10 and 07/13/10. The following data was noted: *no changes in memory or decision making skills; *requires extensive assistance with toilet use; *frequently (tended to be incontinent daily) incontinent of urine (This reflects a decline; change from occasional to frequent); and, *remains on scheduled toilet plan. Surveyor # requested all bladder assessments including voiding patterns completed for Resident #6 since April 2009. The DON stated there had been no additional assessments or diaries completed for Resident #6 from 04/2009 through 07/2010, even though Resident #6 has had 2 noted declines during the MDS assessment schedules. Surveyor # reviewed nurse's notes dated 04/05/10 and 07/05/10, and noted that Resident #6 was continent less than once per day, was unaware of the need to urinate, was never able to state a need to void, had large volumes of incontinence, and disliked sitting on toilet to urinate. Review of the CNA (Certified Nursing Assistant) daily care guide for Resident #6 notes that mechanical lift is required for toilet use, is to be toileted before and after meals, and wears an incontinent brief. Review of the care plan for Resident #6 titled "Alteration in elimination, bowel and bladder incontinence...related to impaired mobility and cognitive deficit" dated 10/13/09, notes Resident #6 is to be taken to the toilet during daytime hours, after meals, as requested and to wear a brief at all times. During the initial facility tour conducted on 12/06/10 beginning at 8:50 a.m., Surveyor # was informed by RN-L (Registered Nurse) that Resident #6 is totally incontinent of urine. On 12/08/10 at 9:25 a.m., Surveyor # interviewed RN-N regarding Resident #6's toilet plan. RN-N stated Resident #6 is incontinent and needs the mechanical lift for toilet use. RN-N stated Resident #6 is to be toileted every 2 hours. Example #2: Resident #14 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed a bladder assessment for on 07/27/09 which noted that Resident #14 had overflow and functional incontinence. Resident #14 was placed on a routine toilet plan; however there was no voiding patterns noted in the assessment. The facility completed an annual MDS for Resident #14 on 12/02/09. The following data was noted: *short and long term memory deficits; *severely impaired daily decision making skills; *requires extensive assistance with toilet use; *frequently (tended to be daily) incontinence; and, *is on a scheduled toilet plan. Review of the urinary incontinence RAP completed on 12/02/09, notes Resident #14 has urinary incontinence due to enlarged prostate and dementia. There is no type of incontinence identified and no voiding patterns noted. The facility completed quarterly MDSs for Resident #14 on 03/03/10, 06/01/10, and 08/31/10. The following data was noted: *no changes in memory or daily decision making; *no changes in assistance for toilet use; *is totally incontinence of urine (This reflects a decline; change from frequent to total incontinence.); and, *remains on scheduled toilet plan. Surveyor # requested all bladder assessments and bladder diaries completed on Resident #14 since July 2009. The DON stated there has been no additional assessments or diaries completed for Resident #14 from 07/09 through 07/10, even though Resident #14 has had 3 noted declines during the MDS assessment schedules. Review of the nurse's notes dated 02/22/10, notes Resident #14 is sometimes aware of the need to urinate and has large volumes of incontinence. Review of the CNA daily care guide, notes Resident #14 is to wear an incontinence brief, is to be offered toileting with cares, before meals, before bed, and as needed. Review of Resident #14's care plan titled "I need assist with ADLs (activities of daily living)" dated 09/01/09, notes Resident #14 needs 1 assist for toilet use. During the initial facility tour conducted on 12/06/10, Surveyor # was informed that Resident #14 is incontinent of urine. On 12/08/10 at 1:00 p.m., Surveyor # interviewed CNA-K regarding Resident #14's bladder control. CNA-K stated she is familiar with Resident #14 as she often cares for him 4 days a week. CNA-K stated Resident #14 is toileted in the morning, after breakfast, and before and after lunch. CNA-K stated Resident #14 has poor control of urine due to continued dribbling. Example #3: Resident #7 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed a bladder assessment for on 01/05/09, which notes Resident #7 has functional incontinence with patterns of increased frequency during the daytime. Resident #7 was placed on a routine toilet plan. The facility completed a quarterly MDS for Resident #7 on 01/06/10. The following data was noted: *short and long term memory deficits; *moderately impaired daily decision making skills; *requires extensive assistance with toilet use; *frequently (tended to be daily) incontinent of urine; and, *is on a scheduled toilet plan. The facility completed an annual MDS for Resident #7 on 04/08/10. The following data was noted: *no changes in memory or daily decision making; *no changes in toilet use assistance; *totally incontinent of urine (This reflects a decline; change from frequent to total incontinence); and, *continues on scheduled toilet plan. Review of the urinary incontinence RAP completed on 04/08/10, notes Resident #7 is incontinent of urine and will occasionally indicate the need to urinate. There is no decline identified, no patterns of voiding identified, and no type of incontinence noted. The facility completed 2 additional quarterly MDS assessments for Resident #7 on 07/06/10 and 10/05/10, with both assessments unchanged from the annual. On 12/07/10, Surveyor # requested all bladder assessments and bladder diaries completed on Resident #7 since April 2010. The DON stated there has been no additional assessments or diaries completed for Resident #7 from 04/2010 through 07/2010, even though Resident #7 has had 3 noted declines during the MDS assessment schedules. Review of the nurse's notes dated 01/03/10 and 04/03/10, notes Resident #7 is incontinent more than once daily and needs help with toilet use. Review of the CNA daily care guide, notes Resident #7 is on a toilet schedule and is incontinent at all times. Review of the care plan titled "Potential for alteration in skin integrity...related to bowel and bladder incontinence..." developed for Resident #7 on an unknown date, notes that staff should monitor for incontinence changes, assist to the toilet when Resident #7 requests, before/after meals, and at bedtime. During the initial facility tour conducted on 12/06/10 beginning at 8:50 a.m., Surveyor # was informed by RN-L that Resident #7 is totally incontinent of urine. On 12/08/10 at 9:25 a.m., Surveyor # interviewed RN-N regarding Resident #7's bladder control. RN-N stated Resident #7 is almost always incontinent. Example #4: Resident #5 was admitted to the facility on [DATE] with the following, but not all inclusive, Diagnoses: [REDACTED]. The facility completed an initial MDS for Resident #5 on 07/27/10. The following data was noted: *short and long term memory deficits; *moderately impaired daily decision making skills; *independent with toilet use; *frequently (tended to be daily) incontinent of urine; and, *is on a scheduled toilet plan. Review of the urinary incontinence RAP completed on 07/27/10, notes Resident #5 is independent in toilet use, but is also incontinent at times. The RAP notes that cognitive deficits impacted urinary incontinence. Review of the CNA daily care guide, notes Resident #5 is to be assisted to the bathroom in the morning and at bedtime, before/after meals, and at night during rounds. Review of the care plan titled "Incontinence, bowel and bladder... related to dementia..." that was developed on 07/27/10 for Resident #5, notes scheduled toileting in the morning and bedtime, before/after meals, and at night. During the initial facility tour conducted on 12/06/10 beginning at 8:50 a.m., Surveyor # was informed by RN-L that Resident #5 is incontinent of urine but has some control. Surveyor # reviewed the entire medical record and was unable to locate any bladder diary or bladder assessment for Resident #5. The medical record did not include any type of incontinence or any voiding patterns identified. The Surveyor requested copies of any bladder diaries or assessments completed for Resident #5, and was informed by the DON, as well as RN-O, that there had been no diaries or assessments completed. On 12/08/10 at 9:15 a.m., Surveyor # interviewed CNA-M regarding Resident #5's bladder control. CNA-M stated that Resident #5 is usually continent due to being offered toileting assistance every hour. CNA-M stated in the past 3 months, Resident #5 has had a decline in bladder control and is now usually incontinent because he often refuses help. On 12/08/10 at 9:25 a.m., Surveyor # interviewed RN-N regarding Resident #5's bladder control. RN-N stated Resident #5 has several incontinent episodes due to getting angry with caregivers. RN-N stated Resident #5 is offered toilet use every hour, but is usually incontinent. Example #5: Resident #8 was admitted to the nursing home on 06/23/08. Resident #8 has [DIAGNOSES REDACTED]. Resident #8's most recent Minimum Data Set Assessment ((MDS) dated [DATE], indicates the following: ~occasionally incontinent of bladder; ~on scheduled toileting plan. Review of Resident #8's most recent care plan and guidelines for daily care with a print date of 10/05/10, indicates, "09/27/10 Toileting: Toileting schedule, prompted toileting, 1/2 hr. before and after meals and when asks. Offer during NOC rounds and prn, offer at 0500 (may use bedpan with illness)." On 12/08/10, Surveyor # received a copy of a bowel and bladder assessment and attached quarterly reviews dated 01/02/09, 04/02/09 and 07/27/09. The assessment did not indicate the type of incontinence. On 12/08/10, Surveyor # received a copy of bowel and bladder evaluation daily worksheets dated 08/06/10-08/09/10. A bladder assessment was not completed with the daily worksheets. On 12/08/10 at 1:25 p.m., Surveyor # spoke with CNA-K (Certified Nursing Assistant). CNA-K indicated that Resident #8 is sometimes incontinent of bladder, and sometimes when Resident #8 is assisted onto the toilet she is incontinent and will also void on the toilet. Example #6 Surveyor # reviewed the medical record of Resident #15. Resident #15 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) dated on 8/6/10, indicates Resident #15's cognition is alert and oriented, and independent with decision making. Resident #15 requires extensive assistance with activities of daily living and also indicates that she was admitted with a Foley catheter. On 8/17/10, the Foley catheter was discontinued. The facility's plan of care dated 9/18/10, indicates a problem of incontinence related to a mobility deficit, lack of awareness of need to void /defecate. The approaches include: wears absorbent products, use bed pan as needed, use protective pads, pericare when incontinent, remind resident to void, wear incontinence briefs, change as needed, cleans peri-area and apply barrier cream to after incontinent episodes and as needed, keep clean and dry. Goal is dated 11/9/10 complications avoided. The Certified Nurse Aide guidelines for daily care under toileting indicates: "1 assist." On 8/18/10, the facility monitored how many times Resident #15 was incontinent, which varied between 1-3 times being incontinent. There is no record of any type of an assessment being completed or type of incontinence documented. The DON gave Surveyor # an undated note, which stated Resident is incontinent of bowel and bladder even though she is toileted; refused a bowel and bladder program stating she did not think it would help since she "has no feeling when she urinates or deficates (sic)" after her fall. Peri area is red due to incontinence, barrier cream applied with cares.