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

Based on observation, staff interview, and record review, the facility did not ensure stock medications, medical supplies, and medications for 2 residents (R) (R178 and R26) in 2 of 4 medication carts and 1 of 2 medication storage rooms were stored, labeled, and/or dated appropriately. A medication storage room contained expired medical supplies. Two medication carts contained open, unlabeled, and expired medications, including medications for R178 and R26. Findings include: The facility's Labeling of Medication Containers policy, revised April 2019, indicates: All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations .2) Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. 3) Labels for individual resident medications include all necessary information, such as: a. The resident's name; b. The prescribing physician's name; c. The name, address and telephone number of the issuing pharmacy; d. The name, strength, and quantity of the drug; .f. The date that the medication was dispensed . The facility's Storage of Medications policy, revised April 2019, indicates: .2) Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received .4) Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing; 5) Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . On 10/1/24 at 1:09 PM, Surveyor observed the main medication storage room and noted the following: ~ Surveyor confirmed with Licensed Practical Nurse (LPN)-C an open and undated plastic bag that contained 21 individual foil packs of Dukal petroleum adaptic gauze non-adherent dressing. LPN-C confirmed there were no expiration dates on the foil packs and the foil packs were not in their original packaging. LPN-C indicated if there were no expiration dates, the items should be discarded. ~ Surveyor confirmed with Registered Nurse (RN)-D one Zyno medical infusion administration set with an expiration date of 7/10/24 and 4 individual packs of [NAME] silicone superabsorbent dressing with expiration dates of 2/2/23. RN-D indicated if the items were expired, they should be thrown away. On 10/1/24 at 1:31 PM, Surveyor observed the 100 unit medication cart and noted the following: ~ A vial of Lantus insulin injection 100/ml (milliliters) for R26 with an open date of 8/22/24 and an expiration date of 9/30/24 written on the label. The label indicated the insulin expired 28 days after opening. Surveyor confirmed with RN-E who indicated the insulin should have been discarded since it was past the expiration date. ~ An open and undated fluticasone furoate/vilanterol ellipta inhalation powder 100 mcg (microgram)/25 mcg inhaler for R178. Surveyor confirmed with RN-E who indicated the inhaler should have been sent back since R178 was no longer in the facility. On 10/1/24 at 1:47 PM, Surveyor observed the 200 unit medication cart and noted the following: ~ An open, unlabeled, and undated package of albuterol sulfate inhalation aerosol 90 mcg/actuation, 200 meters. Surveyor confirmed with RN-E who indicated the package should have an open date and should have been discarded due to the unknown length of time the package was open. On 10/2/24 at 9:05 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated medications and medical supplies that are open, unlabeled, undated, and/or expired should be discarded.

Based on observation, staff interviews, and record review, the facility failed to ensure accurate and safe administration of pharmaceuticals for 4 Residents (R) (R36, R17, R25, and R5) of 20 sampled residents. On 7/25/22, Licensed Practical Nurse (LPN)-C left medications for R36 to take unattended. R36 was not assessed for safe self-medication administration. The facility did not secure or assess for safety at bedside and get an order for R17's Tums (antacid medication). LPN-E left R25's medications at bedside. R25 was not assessed for safe self-medication administration, had a diagnosis of dementia, and had an activated Power of Attorney (POA) for health care decision making. On 7/25/22, Surveyor observed medications left unattended at R5's bedside. R5 was not assessed for safe self-medication administration. Findings include: Facility provided policy titled Self-Administration of Drugs with a revised date of August 2006 stated, .Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so . In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels, b. Comprehension of the purpose and proper dosage and administration time for his or her medications, c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) them, and d. Ability to recognize risks and major adverse consequences of his or her medications . Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for bedside storage . 1. On 7/25/22, Surveyor reviewed R36's medical record. R36 was admitted to facility on 3/21/22 with diagnoses to include acute kidney failure (kidneys suddenly become unable to filter waste products from blood) and age-related cognitive decline (brain does not work as well as it used to which leads to trouble learning, using language, or remembering things). R36's Minimum Data Set (MDS) assessment dated [DATE] stated R36's Brief Interview for Mental Status (BIMS) score was 14 out of 15 which indicated R36 had little cognitive impairment. On 7/25/22 at 8:40 AM, Surveyor interviewed R36. Upon entering the room, Surveyor observed R36 take a medication with a sip of water. Surveyor observed a medication cup on R36's table which contained two tablets, one long red tablet and one small round white tablet. No staff member was present in R36's room. R36 stated, I'm not sure what they are for, I think one is a vitamin. On 7/25/22 at 11:41 AM, Surveyor interviewed LPN-C who was passing medication to other residents in R36's hall. When questioned if R36 was assessed to self-administer medication, LPN-C stated, No. You caught me. I know we're not supposed to do that (leave meds at bedside). On 7/26/22, Surveyor reviewed R36's medical record. R36's medical record did not contain a self-administration assessment for R36. R36's medical record did not contain a physician's order for self-administration of medication. On 7/27/22 at 8:50 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated if a resident was not assessed to self-administer medication, then staff may not leave medication unattended at the resident's bedside. On 7/27/22 at 9:49 AM, DON-B verified R36's medical record did not contain a self-administration of medication assessment, therefore, medication should not have been left in R36's room unattended. On 7/27/22 at 9:56 AM, Surveyor reviewed R36's facility provided Medication Administration History with Registered Nurse (RN)-D who assisted Surveyor with comparing medications in the medication cart for R36 to Medication Administration History for morning med pass on 7/25/22. R36's Medication Administration History indicated R36 received one vitamin D3 (used as a supplement) tablet the morning of 7/25/22 which, RN-D showed Surveyor, was a small round white tablet. R36's Medication Administration History also indicated R36 received one multivitamin (used as a supplement) tablet the morning of 7/25/22 which, RN-D showed Surveyor, was a long red tablet. R36's Medication Administration History further indicated R36 received one calcium (used as a supplement) tablet the morning of 7/25/22 which, RN-D showed Surveyor, was a long white tablet. 2. From 7/25/22 through 7/27/22, Surveyor reviewed R17's medical record which documented an order for calcium [MEDICATION(S)] (active ingredient in Tums) tablets for upset stomach. R17's medical record did not include a self-medication administration safety assessment. Surveyor noted none of R17's medications were ordered to be kept at bedside. On 7/25/22 at 9:47 AM, R17 complained to Surveyor that R17 frequently experienced stomach pain. R17 pointed to a Tums container on R17's bedside table and explained R17 took Tums when R17's stomach hurt. R17 disclosed Tums were not provided by the facility but family brought Tums in. R17 indicated staff were aware of Tums at R17's bedside. On 7/27/22 at 11:26 AM, Surveyor and DON-B entered R17's room. R17 was not in the room at the time. DON-B secured R17's Tums from bedside and vocalized the Tums were not provided by the pharmacy. DON-B indicated R17's family probably brought Tums in. 3. From 7/25/22 through 7/27/22, Surveyor reviewed R25's medical record which documented R25 had an activated POA for health care decision making. R25's diagnoses included dementia. R25's 6/1/22 MDS assessment BIMS score was 5 out of 15 (severe cognitive impairment). R25's Medication Administration Record (MAR) documented R25's 7/25/22 morning medications included acetaminophen (Tylenol), [MEDICATION(S)] (used to treat blood pressure/heart failure), Culturelle (probiotic), [MEDICATION(S)] (vitamin B12), [MEDICATION(S)], [MEDICATION(S)] (anti-depressant), sennosides-[MEDICATION(S)] sodium ([MEDICATION(S)]), and vitamin D3. On 7/25/22 at 9:35 AM, Surveyor observed R25 in bed sleeping. Nine pills were in a cup on R25's bedside table and no staff were present. On 7/25/22 at 10:19 AM, Surveyor interviewed LPN-E regarding R25's medication. LPN-E explained it was LPN-E's usual practice to leave R25's cup of morning medications at bedside. LPN-E's routine included attempting to rouse R25 between 7:00 AM and 7:30 AM. R25 usually was groggy when saying hello, then R25 would roll over and sleep more. LPN-E's practice was to go back later and find R25 took the medications. When asked if R25 was safe to self-administer medication, LPN-E replied, I think the answer you want is 'no'. At 10:23 AM, Surveyor accompanied LPN-E into R25's room. LPN-E verified medications were still in a cup on R25's bedside table. LPN-E counted 9 pills in the cup and indicated LPN-E expected R25 to be up and have taken the medications but now. LPN-E proceeded to wake resident and say, It's 10:30. I want you to take your morning pills. On 7/27/22 at 8:51 AM, DON-B indicated residents assessed as safe to self administer medication had a notice on the electronic MAR banner that documented self-administration exceptions. At that time, Surveyor reviewed R25's electronic MAR with DON-B. DON-B verified R25 was not assessed as safe to self administer medication. From 7/25/22 through 7/27/22, Surveyor reviewed R5's medical record which documented R5's diagnoses included Alzheimer's disease and dementia. R's 5/4/22 MDS assessment BIMS score was 9 out of 15 (moderate impaired cognition). R5's MAR documented R5's 7/25/22 morning medications included vitamin B12, calcium [MEDICATION(S)]-vitamin D3, cranberry plus vitamin C, Culturelle (probiotic), D-mannose powder (urinary tract infection prevention), [MEDICATION(S)] (anticoagulant), famotidine (antacid), [MEDICATION(S)] sulfate (iron supplement), multivitamin, potassium chloride, and vitamin C. R5's medical record did not contain a self-administration assessment for R5 or a physician's order for self-administration of medication. On 7/25/22 at 8:46 AM, Surveyor observed R5 sitting in a recliner with medication sitting on a bedside table in front of R5. Surveyor observed six pills in a cup on R5's bedside table with no staff members present in R5's room. Surveyor asked R5 about the medication left on R5's bedside table and if prefers medication to be left at bedside. R5 stated, It is just what happens, they just leave them. On 7/25/22 at 10:04 AM, Surveyor observed R5 resting in bed watching TV. R5's bedside table was in reach of R5 and six pills were observed in a medications cup on R5's bedside table. On 7/25/22 at 10:52 AM, Surveyor observed R5 asleep in bed with six pills in a medication cup on R5's bedside table. On 7/25/22 at 10:57 AM, Surveyor interviewed LPN-E regarding R5's medication left unattended at bedside. LPN-E stated LPN-E did observe R5 take medication that morning but further stated R5 has started to spit the medication back out after staff leave the room. LPN-E stated LPN-E should have verified R5 had taken the medication. On 7/27/22 at 8:50 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated if a resident was not assessed to self-administer medication, staff may not leave medication unattended at the resident's bedside. Surveyor asked if a resident had a history of spitting out medication after staff had given them to a resident what would DON-B expect staff to do. DON-B stated DON-B would expect staff to reassess the resident, stay longer with the resident and verify the resident swallowed the medication. On 7/27/22 at 9:49 AM, DON-B verified R5 did not have a self medication assessment completed.

Based on observation and staff interview, the facility did not ensure all drugs and biologicals were stored in accordance with currently acceptable standards of practice for 23 residents residing on the 300 and 500 units of 53 total residents. The medication cart used to pass medication to the residents on the 300 and 500 units was observed multiple times unlocked and not in direct supervision of the nurse on duty. On 7/25/22 and 7/27/22, Surveyor observed a [CONDITION(S)] communication binder for R3 that had two pills tucked inside ([MEDICATION(S)] 10 mg (milligrams) used to treat low blood pressure) and left unattended at the nurses' station. Findings include: The facility's policy titled Security of Medication Cart with a revision date of 4/2007 states: 1. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be placed within view of the nurse when entering rooms to administer medications. 3. When it is not possible to park the medication cart within view, the cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view. 1. On 7/25/22 at 9:21 AM, Surveyor noted the medication cart on the 300 unit was in the hall unlocked and not in direct supervision of the nurse on duty. At 9:22 AM, Licensed Practical Nurse (LPN)-E returned to the medication cart. On 7/25/22 at 9:41 AM, Surveyor noted the medication cart on the 300 unit was in the hall unlocked and not in direct supervision of the nurse on duty. LPN-E was observed in a resident's room administering medications. LPN-E's back was toward the medication cart. At 9:42 AM, LPN-E returned to the medication cart. On 7/25/22 at 9:56 AM, Surveyor noted the medication cart on the 300 unit was in the hall unlocked and not in direct supervision of the nurse on duty. At 9:57 AM, LPN-E returned to the medication cart. On 7/25/22 at 9:57 AM, Surveyor interviewed LPN-E regarding the unlocked medication. LPN-E verified the medication cart was left unlocked and not in direct view. LPN-E stated the medication cart should be locked when not in direct sight of LPN-E. On 7/27/22 at 8:51 AM, Surveyor interviewed Director of Nursing (DON)-B regarding medication carts being locked when not in direct sight of a nurse. DON-B verified medication carts should be locked when a nurse is not by the medication cart or walks away. 2. On 7/26/22 at 12:46 PM, Surveyor opened the [CONDITION(S)] communication binder for R3 and observed two pills ([MEDICATION(S)] 10 mg) in a plastic bag used to crush medication tucked in the front pocket of the binder. Surveyor observed the date 7/22/22 on the plastic bag. R3's [CONDITION(S)] communication binder was stored on the nurses' station desk. On 7/27/22 at 10:31 AM, Surveyor observed an unknown staff member drop R3's [CONDITION(S)] binder at the nurses' station. Surveyor opened R3's [CONDITION(S)] binder and observed two pills ([MEDICATION(S)] 10 mg) in a plastic bag stapled to R3's [CONDITION(S)] communication sheet dated 7/27/22. At 10:43 AM, LPN-F grabbed R3's [CONDITION(S)] communication binder and entered the medication storage room. On 7/27/22 at 10:48 AM, Surveyor interviewed LPN-F regarding R3's [CONDITION(S)] communication binder and the medications observed inside. LPN-F stated R3's [CONDITION(S)] communication binder is either placed on the nurses' station desk or in R3's [CONDITION(S)] bag in R3's room. From 7/25/22 through 7/27/22, Surveyor reviewed R3's medical record. R3 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Tape inside R3's [CONDITION(S)] binder once a day on Monday, Wednesday, and Friday AM. On 7/26/22 at 12:47 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R3's [CONDITION(S)] communication binder. NHA-A verified the Surveyor observed two pills in R3's [CONDITION(S)] communication binder and stated, That should not be in there. On 7/26/22 at 1:37 PM, Surveyor interviewed DON-B regarding R3's [CONDITION(S)] communication binder. DON-B stated DON-B expects staff to check R3's [CONDITION(S)] communication binder when R3 returns and verified the medications should not be kept in the [CONDITION(S)] communication binder.

Based on observation, interview, and record review the facility did not provide the necessary respiratory care and services consistent with current professional standards of practice for 1 resident (R) (R6) of 2 residents reviewed for oxygen use. R6 was using oxygen from a concentrator and did not have a physician's order for use, a care plan in place, or a schedule to check the oxygen tubing. Findings include: The facility provided a policy titled; Oxygen Administration dated 3/2004. Under preparation it states: 1. Verify that there is a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. Under assessment it states: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis (i.e. blue tone to the skin and mucous membranes); 2. Signs or symptoms of [CONDITION(S)] (i.e. rapid breathing, rapid pulse rate, restlessness, confusion); 3. Signs or symptoms of oxygen toxicity (i.e. tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); 4. Vital signs. 5. Lung sounds. Under monitoring/tubing changes reporting it states: 1. Standards of practice support oxygen tubing replacement to be event-related instead of time-related. Event-related examples requiring oxygen tubing replacement include: when visibly soiled or when known contamination occurs. R6 was admitted on [DATE] and had related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6 had a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated R6 was cognitively intact. On 7/25/22 at 11:24 AM, Surveyor interviewed R6 as part of the long-term care survey process. Surveyor noted during this interview that R6 was using oxygen. Surveyor could not locate a date on the oxygen tubing and R6 could not recall a staff member changing the tubing. R6 verified R6 had been using the oxygen continually for the last few weeks. Between 7/25/22 and 7/27/22, Surveyor reviewed R6's electronic health record and could not find physician orders, a care plan, or how the facility was monitoring and ensuring the tubing was changed. Surveyor noted R6's progress notes on 7/4/22 at 12:59 AM stated, Upon assessment resident c/o (complained of) dry cough. O2 (oxygen) resting 83%-85% RA (room air) after cough and deep breathe and PRN (as needed) [MEDICATION(S)] utilized. R6 initially refusing O2, with expressions of, I know I have my right to refuse. Upon 3rd attempt with additional education provided, R6 allowed writer to start 2L (liters) of supplemental O2. Lungs - Fine crackles noted to LLL (left lower lobe). +3 pitting [CONDITION(S)] to BLE (bilateral lower extremities) and +1 to bilateral knees. Denies SOB (shortness of breath) at this time. No cognitive changes noted. Resident A/O (alert and oriented) x 3. Updated provider via fax, CHF (congestive heart failure) clinic to be updated in am. Surveyor reviewed progress notes between 7/4/22 and 7/8/22. Surveyor observed documentation for oxygen set to 2-2.5 liters per minute. Surveyor noted R6's care plan was updated on 7/25/22 with Resident has ineffective breathing pattern R/T (related to) CHF, [CONDITION(S)] (hypertension), [CONDITION(S)], chronic respiratory failure. Surveyor did not observe a care plan regarding ineffective breathing pattern prior to 7/25/22. On 7/27/22 at 8:31 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F regarding plans of care for residents on oxygen. LPN-F stated LPN-F would know the amount of oxygen a resident is supposed to be on by looking at the physician orders in the electronic health records. LPN-F verified R6 did not have any orders for oxygen in the electronic health records. LPN-F verified R6 should have orders and monitoring because R6 was using oxygen continually. On 7/27/22 at 9:01 AM, Surveyor interviewed Director of Nursing (DON)-B regarding Surveyor did not observe physician's order for use, a care plan in place, or a schedule to check the oxygen tubing. DON-B stated DON-B expects staff to start oxygen therapy from the standing orders and then expects staff to update a provider and put orders into Matrix (electronic health record) from the response and then update the care plan. DON-B verified the physician orders should have a range depending on the resident's oxygen saturation. On 7/27/22, Surveyor observed new physician orders in R6's electronic health record, dated 7/27/22 at 9:41 AM: O2 at 1-4 L/M (liters per minute) per NC (nasal canula)/Concentrator for respiratory distress/sats (saturation) below 89%. May be off as tolerated. Special instructions: Resident requires portable liquid O2 every shift. Change/check O2 tubing as indicated and clean filter every 5 days. Check behind ears daily for breakdown from O2 tubing once a day. Check O2 sat (saturation) on room air monthly. Special Instructions **Need qualifying room air sat of 88% or less** once a day on the 1st of the month. Surveyor observed the physician orders were put in R6's electronic health record after Surveyor interviewed DON-B. On 7/27/22 at 9:52 AM, DON-B verified no physician orders were put into Matrix. DON-B did provide Surveyor with a Physician Order sheet, dated 7/8/22, with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . DON-B verified R6's progress notes indicated R6 started using oxygen again on 7/4/22. DON-B verified there was not a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interviews, the facility did not ensure allegations of neglect were reported to the State Agency (SA) as required for 1 resident (R) (R1) of 3 resident investigations reviewed. On 8/13/21, R1's family member (FM)-C reported an allegation of neglect related to R1's care to Nursing Home Administrator (NHA)-A. NHA-A did not submit a facility-reported incident (FRI) to the SA. Findings Include: The Surveyor reviewed facility policy titled Abuse Prohibition which read: Policy: Rennes Health and Rehab Centers will assure allegation and incidents of abuse, neglect, mistreatment, exploitation and misappropriation are reported immediately to the administrator or designee and DQA (Division of Quality Assurance), to be as soon as possible, but not to exceed 24 hours after discovery of the incident. These allegations are thoroughly investigated with the results of all investigations to be reported to the administrator (or their designee) and to the DQA Office of Caregiver Quality (OCQ) within 5 working day of the incident. Procedure: .The Administrator/or designee will immediately report all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, exploitation and misappropriation of resident property to DQA. Immediate, as defined by CMS, to be as soon as possible but not to exceed 24 hours after discovery of the incident. Definitions: Neglect: Means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. On 10/20/21, the Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan read: Resident at risk for skin breakdown r/t (related to) immobility, incontinence (loss of urine and/or bowels). Assure change of position every 1-2 hours. Keep clean and dry as possible. Minimize skin exposure to moisture. Provide incontinence care after each episode. Alteration in elimination r/t incontinence of bladder and bowel. [CONDITION(S)] (urinary tract infection) 9/2017. Toilet after meals and at the start of the PM shift/first round of the PM shift. Check/change/toilet q (every) 1-2 H (hours) while awake and during the night at 11 PM, 1 AM and 5 AM rounds per family request. On 10/20/21 at 8:30 AM, the Surveyor reviewed the facility's grievance file which included two grievances from June 2021 thru September 2021. On 10/20/21 at 9:29 AM, the Surveyor interiewed FM-C. FM-C stated that on 8/13/21, FM-C reported to NHA-A that R1 was neglected by facility staff. FM-C further explained that R1's Libre sensor (a blood glucose monitoring device) which was located on R1's upper arm went missing between 7 and 730 AM the morning of 8/10/21 and staff reported to FM-C that the sensor was found in R1's incontinence brief (a form of underwear that help contain/absorb urine) on the evening of 8/10/21 at approximately 8 PM. FM-C alleged that this would indicate that R1 was not checked/changed for incontinence episodes for 11 hours. FM-C further indicated that R1 has a history of UTIs with an occurrence of [CONDITION(S)] (a life-threatening condition which is triggered by an infection in the body) for which R1 needed to be hospitalized in the past. FM-C indicated that R1 cannot verbalize R1's needs nor can R1 utilize a call light. FM-C indicated that the facility utilized an incontinence brief and an insert inside the brief to collect urine for incontinence episodes due to R1 taking medication that causes heavy amounts of urination/wetting. FM-C confirmed that the word neglect was used by FM-C during the conversation with NHA-A. On 10/20/21 at 10:00 AM, the Surveyor interviewed NHA-A. NHA-A confirmed that FM-C contacted NHA-A with concerns about R1. NHA-A indicated having a soft-file on that (referring to allegation by FM-J). Upon request by the Surveyor, NHA-A then provided a document which was titled Resident Grievance/Complaint Investigation Report Form. The document was dated 8/13/21; and read as follows: Provide a summary of the grievance or complaint: (Complainant) reports that (complainant) is upset that (R1's) Libre sensor was missing the morning of 8/10 and not found until 8 PM the same day. The sensor was found on the side of (R1's) brief, thus (complainant) states that (complainant) thinks only R1's insert was changed and not the whole brief. States that staff is lazy and that (complainant) believes (R1) was in a wet brief for 11 hours. States (complainant) thinks this happened to (R1) because (R1) can't talk. Upon further interview with NHA, NHA-A indicated that an investigation was conducted in which staff working on 8/10/21 were interviewed and education was given to staff related to following care plans. Upon request, NHA-A then provided the investigation documents to include staff interviews, resident interviews, staff education and facility audits. Staff interview documentation indicated that R1 was checked for incontinence on 8/10 at 12:30 PM and not again until after the supper meal (after 5:30 PM). NHA-A confirmed that R1 utilized an incontinence brief and also an insert is put inside the brief. NHA-A explained that R1 has episodes of urinary incontinence and heavy wetting related to medication also noting the insert is utilized as a means to try to prevent urine from soaking through R'1s clothing. On 10/20/21 at 12:53 PM, the Surveyor interviewed Registered Nurse (RN)-E. RN-E confirmed working PM shift on 8/10/21(2:30 to 10:45 PM). RN-E indicated that at the beginning of the shift, RN-E was notified by the day nurse that R1's Libre sensor was missing and that they (staff) had been looking all day for it. On 10/20/21 at 1:37 PM, the Surveyor interviewed, CNA (Certified Nursing Assistant)-D. CNA-D confirmed working 2nd shift (2:30 to 9 PM) on 8/10/21 and being the staff member who located R1's Libre sensor within R1's incontinence brief after the supper meal. CNA-D explained the sensor was located inside R1's brief near the left groin area. CNA-D indicated that it was busy that night and there were 2 other CNAs working the same unit; CNA-D stated not being familiar with the unit as CNA-D is not usually assigned to that unit and that CNA-D had assumed the other two CNAs had toileted R1 prior. The Surveyor reviewed the CNA schedule for R1's unit for 8/10/21. The Surveyor reviewed staff statements which were provided by NHA-A. Each of the other CNAs working with R1 on 2nd shift indicated that they thought the other CNA had assisted R1 with incontinence care/toileting needs. Day shift CNA statements were reviewed and indicated R1's last check for incontinence was completed at 12:30 PM at which time R1's incontinence products were dry. Nurse's statement included that R1's Libre sensor was noted to be missing at 8:45 AM on 8/10/21. On 10/20/21 at 1:54 PM, the Surveyor interviewed NHA-A. NHA-A confirmed R1's care plan indicated check and change every 1-2 hours and that this did not occur. NHA-A confirmed that a FRI was not submitted to the SA related to R1's family member's allegation due to NHA-A investigating and NHA-A's determination the there was a break down in communication amongst PM shift CNAs.

Based on observation, staff interviews, and record review, the facility did not ensure food was prepared under sanitary conditions with the potential to effect 72 of 73 residents at the facility (1 resident tube fed.) The facility did not ensure food-contact and non-food contact equipment including meat slicer, mixing bowl and can opener was clean and dry for storage or use. The facility did not ensure the warewashing machine (dishwasher) was reaching the minimum 180 degree Fahrenheit (F) temperature required for hot water sanitization. Findings include: On 6/21/21 at 8:39 AM, Dietary Manager (DM)-J indicated the facility utilized ServSafe as the kitchen's standard of practice. ServSafe is based on the Food and Drug Administration (FDA) Food Code. Food-Contact Equipment FDA Food Code 2017 documents 4-602.12 Cooking and Baking Equipment. (A)The FOOD-CONTACT SURFACES of cooking and baking EQUIPMENT shall be cleaned at least every 24 hours. 4-602.13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 6/21/21, during initial kitchen tour beginning at 8:39 AM, Surveyor observed and DM-J verified the meat slicer was covered for storage but had visible food residue under the cutting ledge, the mixing bowl was covered for storage but wet inside, the can opener was not yet used for the day but had red and black residue on the cutting edge and a powdery substance near the handle connection. At the time of observation, DM-J indicated the state of cleanliness of meat slicer, mixing bowl, and can opener were not acceptable and directed staff to clean each item. Hot Water Sanitization FDA Food Code 2017 documents 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures.(A)Except as specified in ¶ (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194oF), or less than: . (2) For all other machines, 82oC (180oF). On 6/21/21 at 9:10 AM, Surveyor observed dishwasher hot water sanitizing rinse cycle temperatures were 178, 174, and 178 degrees F. Trays from these loads contained serving trays, plates, cups, glasses, and lids for cups. At the time of observation, Surveyor requested Dietary Aide (DA)-K, who was operating the dishwasher, to observe temperature with Surveyor for third load observed. DA-K verified the sanitizing rinse was supposed to reach 180 degrees F at a minimum but was not. DA-K explained that sometimes the temperature fluctuated, especially during breakfast dish time, in relation to laundry being washed at the same time in the building. DA-K indicated the procedure was to wait for a time for the heat to build again. DA-K waited approximately two minutes and attempted to re-wash the third load observed but the maximum temperature reached 173 degrees. DA-K indicated DA-K would wait longer. Surveyor observed the first two trays observed below temperature were already put away for service. Immediately following observation, Surveyor interviewed DM-J, who indicated staff should not wait but run the same load several times to bring the machine up to an acceptable temperature before proceeding.

Based on observation, interview and record review, the facility did not ensure implementation of an infection control policy designed to prevent the development and transmission of disease and infection which had the potential to affect: ~1 resident (R) (R23) of 5 sampled and supplemental sampled residents on transmission based precautions, ~2 residents (R33 and R62) of 14 sampled and supplemental sampled residents during 3 of 16 care observations and ~8 residents (R58, R47, R35, R11, R10, R9, R74, and R67) of 8 residents observed on the 100 wing at lunch pass who were not offered hand hygiene prior to eating lunch. 1. Staff did not utilize appropriate Personal Protective Equipment (PPE) when entering R23's room for cares and interactions. 2. Certified Nursing Assistant (CNA)-D did not consistently perform hand hygiene when providing care to R33. In addition, Registered Nurse (RN)-H did not consistently perform hand hygiene when conducting point-of-care testing for R33 3. CNA-E and CNA-I did not consistently perform hand hygiene when providing care to R62. 4. Staff did not offer hand hygiene to 8 Residents on 100 wing prior to the lunch meal on 6/21/21. Findings include: The facility's untitled document identified as facility policy for Droplet Precautions with most recent update date of 3/19/21 stated, Symptomatic residents will be placed on droplet precautions. Droplet precautions will be implemented for symptomatic residents or those with known Covid-19 (a mild to severe respiratory illness that is caused by a coronavirus and at the time of this situation considered pandemic, meaning worldwide spread) exposure. That means: - Place a droplet precaution sign and cart with supply of PPE outside of the room entrance. PPE supply will include N95's (N-95 masks, particulate-filtering facepiece respirator that meets the U.S. National Institute for Occupational Safety and Health (NIOSH) N95 classification of air filtration, meaning that it filters at least 95% of airborne particles) before entering room and surgical masks for use when exiting room. - Use of gowns, eye protection, and N95's before entering room for any reason. - Staff will remove all PPE (including N95) prior to exiting room per doffing (removing) practices - Place surgical masks upon exiting room. Facility provided document titled Handwashing/Hand Hygiene with revision date of April 2020 which stated, This facility considers hand hygiene the primary means to prevent the spread of infections . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies . 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); d. Before and after performing any invasive procedure (e.g., fingerstick blood sampling) . r. After handing soiled or used linens, dressings, bedpans, catheters and urinals . u. After removing gloves . 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% (percent) [MEDICATION(S)] or [MEDICATION(S)] (both [MEDICATION(S)] and [MEDICATION(S)] are alcohol based and suitable for sanitizing at specific concentrations) for all the following situations: a. Before and after direct contact with residents . g. After contact with a resident's intact skin; h. After handling used dressings, contaminated equipment, etc.; i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; and j. After removing gloves . 1. On 6/21/21, Surveyor reviewed R23's medical record. R23 was admitted to the facility on [DATE]. R23's Minimum Data Set (MDS) dated [DATE] stated R23's Brief Interview for Mental Status (BIMS) score was 11 of 15 which indicated R23 had moderate cognitive impairment. On 6/21/21 at 9:11 AM, Surveyor observed a sign attached to the upper doorframe of R23's room which stated, STOP please see nurse before entering D (the letter which indicated Droplet Precautions) discard N95 and replace with mask upon exit. On 6/21/21 at 11:41 AM, Surveyor observed CNA-C enter R23's room without additional PPE other than the surgical mask CNA-C was already wearing on the unit. CNA-C was observed to provide a meal tray to R23's roommate. Surveyor observed the previously posted sign from above paragraph was no longer there. On 6/21/21 at 11:42 AM, Surveyor observed CNA-D enter R23's room without additional PPE other than the surgical mask CNA-D was already wearing on the unit. CNA-D was observed to provide a meal tray to R23. On 6/21/21 at 11:56 AM, Surveyor interviewed CNA-C who, when questioned why the previously mentioned sign was no longer on R23's door stated, I'm not sure but I'll check with the nurse. After checking with R23's nurse, CNA-C indicated R23 was still in Droplet Precautions and stated, Housekeeping accidentally took the sign down. [R23]'s got a couple more days (to be in Droplet Precautions). Surveyor observed CNA-C apply gown, goggles and gloves and, wearing same surgical mask CNA-C was already wearing on unit, enter R23's room, place a garbage can near R23's door and assist R23 to a sitting position on R23's bed to eat R23's meal. Surveyor observed CNA-C remove gloves, gown and goggles, perform hand hygiene, remove surgical mask, perform hand hygiene and apply a new surgical mask as CNA-C exited R23's room. On 6/21/21 at 12:09 PM, Surveyor observed the above referenced sign was back on the upper doorframe of R23's room. On 6/22/21 at 9:50 AM, Surveyor reviewed R23's medical record which contained the following nursing progress notes: ~ 6/02/21: POA (Power of Attorney for Healthcare agent, the person responsible for R23's healthcare decisions) declined offer for resident to receive Covid-19 vaccine. ~ 6/15/21: This am (morning), resident noted to have congested cough. Mild SOB (shortness of breath) with activity. Afebrile (without fever). Lungs: audible air passage through narrower airway heard in upper and mid lungs bilaterally (both sides). Very diminished to both lower lobes. No stridor (an abnormal, high-pitched sound produced by turbulent airflow through a partially obstructed airway) noted. R/T (related to) resident frequently in bed. Resident helped to sit up and worked with deep breathe and coughing. Some improvement noted. O2 (oxygen) saturation has remained WNL (within normal limits). Placed on droplet precautions. Provider updated . of above. ~ 6/15/21: Spoke with POA/[family connection and name] r/t (related to) resident's respiratory status change and isolation implemented as noted today, POA adamantly declines for resident to have Covid (covid-19) swab (test) completed, risks vs (versus) benefits provided with POA decision remaining same. ~ 6/15/21: Spoke with resident's POA, [name], regarding N.O. (new orders) per [provider name]. Residents POA denied rapid covid swab, as well as, the ASAP (as soon as possible) chest x ray order. Resident's POA, states (despite education), 'just skip the chest x-ray for now, there is no need to blast [R23] with [CONDITION(S)].' POA is allowing CBC (complete blood count) w/diff (with differential), BMP (basic metabolic panel), CRP (C-reactive protein) today, and the [MEDICATION(S)] (medication used for the temporary relief of coughs) 200mg (milligrams) po (orally) q4 (every four) hours PRN (as needed), along with the breathing exercises to be initiated. On 6/22/21 at 10:09 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated R23 was on Droplet Precautions because R23 exhibited respiratory symptoms. DON-B indicated facility notified local Department of Public Health (DPH) and was advised by DPH to treat R23's case like a known positive for Covid-19 because R23's POA had refused testing for Covid-19 and refused R23 to be vaccinated against Covid-19. DON-B indicated R23's roommate had also developed respiratory symptoms and was placed on Droplet Precautions and that, because R23's roommate had previously received Covid-19 vaccine series and had tested negative for Covid-19, DPH instructed facility to discontinue R23's roommate's isolation period after 72 hours of being symptom-free. DON-B indicated R23's roommate was removed from Droplet Precautions on 6/22/21 and that there was a miscommunication with facility's housekeeping department who thought both residents in R23's room were off precautions on 6/22/21. When questioned about expectation for staff when entering R23's room, DON-B stated, They (staff) should wear proper PPE when working with [R23]. Would not need PPE when caring for roommate. Privacy curtains should be pulled (closed) to keep separation. When questioned about separation protection when staff cross in front of R23's bed to gain access to R23's roommate, DON-B indicated R23's privacy curtain should be pulled around the end of R23's bed for separation from staff who enter. (Of note: R23's bed was immediately to the left upon entrance to room) On 6/22/21 at 11:06 AM, Surveyor observed privacy curtain in R23's room pulled closed between R23 and R23's roommate. Surveyor observed R23's privacy curtain pulled across end of bed facing doorway. On 6/22/21 at 11:35 AM, Surveyor observed CNA-E deliver meal tray to R23's roommate without use of PPE other than surgical mask CNA-E had been wearing on unit. On 6/22/21 at 11:39 AM, Surveyor observed CNA-E don (put on) gown and gloves, had on same surgical mask CNA-E had been wearing on unit and, without eye protection, entered R23's room to deliver meal tray to R23 then closed room door. On 6/22/21 at 11:43 AM, Surveyor observed CNA-E exit R23's room without gown or gloves. CNA-E was observed to remove surgical mask, perform hand hygiene and put on new surgical mask. Surveyor interviewed CNA-E regarding PPE CNA-E wore in R23's room. CNA-E stated, I forgot eye protection. On 6/23/21 at 8:00 AM, Surveyor observed privacy curtain not pulled around R23's end of bed but rather pulled to end of bed against wall and tucked between wall and R23's bed. R23 was observed sitting next to bed facing doorway and bed. Privacy curtain between R23 and roommate was closed. R23's roommate was not in the room. On 6/23/21 at 8:23 AM, Surveyor observed RN-F delivered meal tray to R23 without donning (putting on) additional PPE except surgical mask RN-F was wearing on unit. RN-F left R23's room after performing hand hygiene but without changing to new mask. RN-F proceeded to deliver a meal tray to another resident in small dining area and assist that resident with eating task. On 6/23/21 at 8:38 AM, Surveyor observed R23 coughing. On 6/23/21 at 8:45 AM, CNA-E entered R23's room after donning gown, gloves and goggles but with same surgical mask CNA-E had been wearing on unit. After attending to R23's needs, CNA-E was observed to remove gown and gloves, perform hand hygiene, exit R23's room, remove goggles, and perform hand hygiene without changing to new mask. On 6/23/21 at 8:50 AM, Surveyor interviewed CNA-E who stated, I know, I forgot to change my mask. On 6/23/21 at 8:52 AM, Surveyor interviewed RN-F who indicated RN-F normally worked at the facility's sister-facility in the same town. RN-F stated, I came from [sister-facility] to help out. I did not realize [R23] was on precautions. I didn't see sign above door. RN-F indicated RN-F was used to seeing precaution signs placed at eye-level at the sister-facility RN-F usually worked at. On 6/23/21 at 10:25 AM, Surveyor interviewed DON-B who indicated staff caring for residents in Droplet Precautions were expected to always don gown, gloves, eye protection and an N-95 mask then change to a new surgical mask when exiting room. 2. On 6/21/21, surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE], R33's MDS dated [DATE] stated R33's BIMS score was 99 which indicated R33 was unable to complete the interview. On 6/21/21 at 10:17 AM, Surveyor observed CNA-D and RN-G assisted R33 with toileting needs. During the provision of care, CNA-D had, with gloved hands, pulled R33's pants and used incontinence product down before lowering R33 onto toilet using mechanical lift. After touching R33's clothing items, CNA-D stated, I touched [R33's] pants and, with gloved hands, obtained alcohol based hand rub from dispenser on bathroom wall, performed hand hygiene of gloved hands and proceeded to use lift controls to lower R33 onto the toilet. On 6/21/21 at 10:30 AM, Surveyor interviewed CNA-D who stated, I made a mistake. I don't normally use hand sanitizer on gloves. CNA-D verified CNA-D should have removed gloves, performed hand hygiene and reapplied gloves to proceed with care task. On 6/22/21 at 8:25 AM, Surveyor observed RN-H obtain point-of-care fingerstick blood sampling for R33. Prior to obtaining samples, RN-H donned clean gloves. After samples were obtained, RN-H removed RN-H's gloves, put point-of-care equipment in associated containers, gathered used items for garbage, placed used items in garbage can then RN-H performed hand hygiene. On 6/22/21 at 8:36 AM, Surveyor interviewed RN-H who indicated hand sanitizer was not placed well in R33's room. Surveyor with RN-H observed that hand sanitizer wall unit was placed on wall behind R33's roommate's recliner in such an area that staff would not be able to reach easily. RN-H indicated RN-H could have asked the facility for pocket-size hand sanitizer. On 6/23/21 at 10:10 AM, Surveyor interviewed DON-B who verified staff should not use hand sanitizer on gloved hands. DON-B verified RN-H should have performed hand hygiene immediately after the removal of gloves. 3. On 6/21/21, Surveyor reviewed R62's medical record. R62 was admitted to the facility on [DATE]. R62's MDS dated [DATE] stated R62's BIMS score was 99 which indicated R33 was unable to complete the interview. On 6/22/21 at 12:26 PM, Surveyor observed CNA-E and CNA-I provide urinary catheter care to R62. During the provision of care, CNA-I was observed to move R62's urinary catheter bag to R62's bed and place it in a privacy bag. CNA-I was observed to removed CNA-I's gloves, move R62's bed away from the call, detach R62's call light cord from the wall and reattach R62's call light cord to the wall before CNA-I performed hand hygiene and applied clean gloves to proceed with care. After cares were provided, R62's clothing was adjusted and R62 was positioned in bed, both CNA-E and CNA-I were observed removing gloves and reapplying clean gloves without performing hand hygiene between glove changes. CNA-E proceeded with emptying R62's catheter bag and CNA-I proceeded with rearranging R62's room. On 6/22/21 at 12:52 PM, Surveyor interviewed CNA-E who verified CNA-E should have performed hand hygiene immediately after removing gloves. On 6/22/21 at 12:52 PM, Surveyor interviewed CNA-I who verified CNA-I should have performed hand hygiene immediately after removing gloves. On 6/23/21 at 10:17 AM, Surveyor interviewed DON-B who verified CNA-E and CNA-I should have performed hand hygiene immediately after glove removal. 4. On 6/21/21 at 12:02 PM, the Surveyor observed C.N.A (Certified Nursing Assistant)-L pass lunch trays on the 100 wing. No hand hygiene was offered to R58, R47, R35, R11, R10, R9, R74, and R67 prior to eating. On 6/21/21 at 12:07 PM, the Surveyor interviewed CNA-L regarding resident hand hygiene before meals. CNA-L verified CNA-L did not offer hand hygiene to any of the above residents prior to eating. CNA-L further stated that CNA-L just forgot about providing hand hygiene to the residents who were eating in their rooms. On 6/21/21 at 12:05 PM, the Surveyor interviewed R47 regarding whether R47 was offered hand hygiene prior to eating. R47 had a BIMS (Brief Interview for Mental Status) score of 15/15 indicating R47's cognition is intact. R47 stated hand hygiene was not offered to R47 prior to the lunch meal. On 6/21/21 at 12:10 PM, the Surveyor interviewed R11 regarding whether R11 was offered hand hygiene prior to eating. R11 had a BIMS score of 14/15 indicating R11's cognition is intact. R11 stated hand hygiene was not offered to R11 prior to the lunch meal. On 6/21/21 at 1:52 PM, the Surveyor interviewed DON-B regarding resident hand hygiene before meals. DON-B indicated the expectation is that residents are provided hand hygiene prior to meals and that usually the staff have hand wipes on the unit for the meal pass, however, they did not for the lunch meal.

Based on record review and staff interview, the facility did not ensure the resident environment remained free of accident hazards for 1 Resident (R) (R1) of 5 sampled residents. R1's most recent therapy evaluation stated R1 required the assistance of two staff for transfers and bed mobility. On 12/20/19, one staff positioned R1 on top of a firm air mattress and slide sheet in preparation for a sit-to-stand transfer. Prior to the transfer, R1 slid off the bed and incurred a left distal femur fracture. Findings include: On 1/21/2020, the Surveyor reviewed a complaint filed with the State Agency. The complaint stated CNA (Certified Nursing Assistant)-C assisted R1 in bed from a supine to a sitting position in preparation for a sit-to-stand transfer on 12/20/19. Prior to the transfer, R1 was seated on the edge of the bed on top of a slide sheet and firm air mattress. When CNA-C left R1's side to retrieve the lift sling, R1 slid off the bed. On 12/27/19, an X-ray confirmed R1 incurred a left femur (thigh bone) fracture. R1 was not a surgical candidate due to multiple comorbidities. R1 returned to the facility with a leg immobilizer, was placed on hospice and now requires a Hoyer lift for transfers. On 1/21/2020, the Surveyor reviewed a self-report submitted to the State Agency on 12/28/19. The self-report stated R1 sustained a fall on 12/20/19 to the left side of the body. A femur fracture was discovered on 12/28/19 after R1 reported pain, displayed weakness with transfers and FM (Family Member)-D observed swelling in R1's left knee. The X-ray noted a distal femoral peri-hardware left leg fracture (a [MEDICAL CONDITION] bone just above the hardware of R1's left knee replacement). The Surveyor reviewed R1's medical record. R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's most recent Quarterly MDS (Minimum Data Set), dated 11/13/19, indicated R1 was severely cognitively impaired and required extensive assistance of two staff for transfers and bed mobility. As of (YEAR), R1 had both knees replaced, left hip surgery and a rod inserted in the left leg. R1 was 5'7 tall and weighed 243 pounds. During an interview with the Surveyor on 1/21/2020 at 10:30 AM, FM-D indicated CNA-C knew R1 was a two person assist for bed mobility and could no longer sit independently upright in bed due to poor trunk strength. FM-D stated, (CNA-C) said (CNA-C) made a careless choice to start the transfer by (CNA-C's) self. During an interview with the Surveyor on 1/22/20 at 12:19 PM, CNA-E stated CNA-C asked CNA-E to help transfer R1; however, CNA-E was in the process of assisting a resident to the dining room. CNA-E stated, When I went in (R1's) room, (R1) had slid off the bed and was on the floor. When asked if R1 required the assistance of one or two staff for bed mobility, CNA-E stated, We were doing one assist with bed mobility. CNA-E stated PT (Physical Therapist)-F observed staff transfer R1 one week prior to R1's fall. CNA-E stated, I used to raise the head of the bed without making (the air mattress) firm. (PT-F) said we had to make the (mattress) firm first. CNA-E couldn't recall if PT-F stated whether one or two staff were needed for bed mobility. The Surveyor reviewed a therapy evaluation, dated 12/08/19, that stated R1 required the assistance of two staff and a side rail for bed mobility as well as the assistance of two staff for Hoyer lift transfers. The Surveyor reviewed a therapy evaluation, dated 12/16/19, that stated R1 required the assistance of two staff for bed mobility as well as sit-to-stand transfers. During an interview with the Surveyor on 1/21/2020 at 3:30 PM, PT-F stated R1 had an air mattress which was always an issue with a sit-to-stand lift. PT-F stated, The biggest problem with sit-to-stands is getting someone from a supine (horizontal) position to sitting on the edge of the bed. After reviewing R1's therapy evaluations on 12/08/19 and 12/16/19, PT-F verified R1 required the assistance of two staff for bed mobility. During an interview with the Surveyor on 1/21/2020 at 2:30 PM, DON (Director of Nursing)-B stated when therapy staff conducted training with the CNAs, therapy staff indicated it was okay to sit R1 upright in bed with one CNA; however, the CNA needed to support R1 and could grab the lift sling with the other hand. During an interview with the Surveyor on 1/22/2020 at 12:27 PM, RN (Registered Nurse)-G stated RN-G and CNA-E entered R1's room at the same time on 12/20/19 and observed R1 on the floor. RN-G asked CNA-C why R1 was positioned on the edge of the bed on top of a slide sheet with one staff present prior to the fall. RN-B stated CNA-C indicated CNA-C was waiting for CNA-E to assist with the transfer. During an interview with the Surveyor on 1/22/2020 at 1:20 PM, DON-B stated the abbreviated care plan used by CNA staff on 12/20/19 no longer existed. DON-B stated care cards were updated thrice weekly and previous care cards were not saved. DON-B stated if a change was made to a resident's care plan prior to an update day, staff were notified via twenty-four hour report and a whiteboard they were instructed to check. DON-B stated R1's 12/16/19 therapy evaluation would have been hung on the whiteboard. DON-B verified the therapy evaluation stated R1 required the assistance of two staff for bed mobility. DON-B stated DON-B wasn't aware of the therapy evaluation prior to 1/22/2020 and didn't realize R1 was transferred incorrectly. DON-B verified staff education was not yet completed regarding the incorrect transfer. During an interview with the Surveyor on 1/23/2020 at 3:25 PM, MD (Medical Doctor)-H stated MD-H saw R1 due to the complexity of (R1's) case after R1 was seen by both an ER (emergency room ) doctor and MD-H's partner. MD-H stated R1's fracture was most likely caused by a traumatic injury. MD-H stated MD-H and FM-D discussed the fact R1 wasn't a good surgical candidate; however, MD-H stated R1 didn't need hospice care due to the fracture. MD-H stated there was an option to place R1 in an immobilizer (a lightweight device worn to keep the knee from bending), let the fracture heal and see if R1 could bear weight in the future. MD-H stated, I don't think (family) wanted further treatment and that's why hospice was initiated. MD-H stated R1's quality of life decreased as a result of the fracture; however, R1 was mostly immobile prior to the fracture. The Surveyor left a voice message for CNA-C on 1/22/2020 at 9:49 AM. As of this writing, the call was not returned.

Based on staff interviews and record review, the facility did not ensure residents were offered the opportunity to create a Power of Attorney for Health Care (POAHC) for 3 Residents (R) (R19, R47, and R57) of 5 residents reviewed for advanced directives. R19 did not have a POAHC or documentation of an offer to create POAHC at the start of survey. R19 created a POAHC during survey after Surveyor began investigating. R47 did not have a POAHC or documentation of an offer to create POAHC. R57 did not have a POAHC. The process was initiated to create a POAHC document on a previous admission, but was never followed up on by the facility. Findings include: 1. On 8/5/19, Surveyor reviewed R19's medical record and noted POAHC paperwork was not on file. On 8/6/19 at 11:39 AM, Nursing Home Administrator (NHA)-A verified to Surveyor that R19's medical record did not contain POAHC advanced directive and no documentation was on file that POAHC creation was offered. NHA-A verified R19 was a long time resident. On 8/7/19 at 9:23 AM, Surveyor interviewed Social Worker (SW)-B regarding R19's POAHC. SW-B indicated R19 created a POAHC advanced directive yesterday (8/6/19) after being offered. SW-B explained a typical practice of offering assistance in creating POAHC documents to new residents and on an annual basis afterward. SW-B's usual practice was to document the offer in a resident's medical record. SW-B verified there was no record of offering in R19's medical record. 2. On 8/6/19, the Surveyor reviewed R47's medical record and noted POAHC paperwork was not on file. On 8/6/19 at 10:23 AM, the Surveyor interviewed R47 who verified R47 was not offered to create a POAHC document. On 8/6/19 at 1:32 PM, the Social Worker (SW)-B verified to the Surveyor that R47's medical record did not contain a POAHC document and no documentation was on file that POAHC creation was offered. 3. On 8/6/19 the Surveyor reviewed R57's medical record and noted the following documentation from the SW ~3/28/19 POAHC paperwork was started in the hospital and R57 wanted to complete the paperwork during R57's stay at the facility. ~4/4/19 R57 was in the process of completing the Five Wishes POA document. ~5/9/19 R57 was transitioning to home on 5/11/19. ~7/3/19 R57 readmitted to the facility from [NAME]in Hospital-Oconto. On 8/6/19 at 1:02 PM, the Nursing Home Administrator (NHA)-A verified to the Surveyor that R57's medical record did not contain a POAHC document and that no further follow-up had taken place with R57 to complete a POAHC document since readmission to the facility on [DATE].

Based on resident interviews, staff interview, and record review, the facility did not ensure care plans were developed to monitor for efficacy and side effects of high risk medication for 2 Residents (R) (R7 and R19) of 7 residents reviewed for medications. R7 did not have a care plan to monitor for efficacy and side effects of [MEDICATION NAME] (an anticoagulant/blood thinner medication). R19 did not have a care plan to monitor for efficacy and side effects of [MEDICATION NAME] (an anticoagulant/blood thinner medication). Findings include: 1. On 8/5/19 at 10:01 AM, R7 disclosed the use of an anticoagulant to Surveyor and mentioned current bruising of R7's left arm. R7 indicated laboratory values were checked periodically but was uncertain if staff were monitoring for side effects of the anticoagulant medication. On 8/6/19, Surveyor reviewed R7's medical record and noted an order, dated 8/6/19, for [MEDICATION NAME] tablet, 2.5 milligrams (mg) at bedtime with instructions to recheck International Normalized Ratio (INR - lab value) on 8/20/19. Surveyor noted R7's care plan did not include information about monitoring for efficacy or side effects related to [MEDICATION NAME]. On 8/7/19 at 10:02 AM, Surveyor interviewed Registered Nurse (RN)-C regarding R7's care plan. RN-C verified being the RN Unit Manager responsible for creating and updating R7's care plans. RN-C reviewed R7's care plan and orders with Surveyor. RN-C recalled R7 being on [MEDICATION NAME] and verified there was a current order but no care plan. RN-C explained the usual practice is to create a care plan for anticoagulant use which included monitoring of possible negative side effects. RN-C affirmed R7 should have an anticoagulant care plan. 2. On 8/5/19 at 9:34 AM, Surveyor interviewed R19 who indicated there was some bruising on R19's body. R19 was not certain about anticoagulant use but believed the bruising may be related to an anticoagulant. On 8/6/19, Surveyor reviewed R19's medical record which documented an order, dated 6/12/19, for [MEDICATION NAME] tablet, 75 mg at bedtime. Surveyor noted R19's care plan did not include information about monitoring for efficacy or side effects related to [MEDICATION NAME]. On 8/7/19 at 9:57 AM, Surveyor interviewed RN-C regarding R19's anticoagulant. RN-C could not recall R19 being on [MEDICATION NAME]. At the time of interview, RN-C reviewed R19's orders, verified [MEDICATION NAME] use without an associated care plan for monitoring. RN-C explained a practice of putting a care plan in place when any anticoagulant is prescribed which would include monitoring for side effects such as signs and symptoms of bleeding and labs that need to be drawn.

Based on record review and staff interview, the facility did not ensure a resident POA (power of attorney) and neurologist were notified when 1 Resident (R1) of 1 resident reviewed repeatedly refused or was unable to take medication for [MEDICAL CONDITION]. R1 received medication for [MEDICAL CONDITION]. R1 experienced an acute change in condition related to R1's refusals and/or inability to take the medication as ordered. R1's POA and neurologist were not notified R1 wasn't taking the medication as prescribed prior to R1's development of Parkinsonism-Hyperpyrexia Syndrome (a rare but potentially life-threatening complication of the management of [MEDICAL CONDITION]) which required R1 to be hospitalized . Findings include: On 6/24/19, the Surveyor reviewed a complaint filed with the State Agency. The complaint indicated R1 was prescribed [MEDICATION NAME] (a medication used to treat Parkinson-like symptoms such as shakiness, stiffness and difficulty moving) for [MEDICAL CONDITION]. On 6/17/19, R1 was transported to a local hospital for a high fever, unresponsiveness and stiff limbs. It was eventually determined R1 was going through withdrawal from not receiving [MEDICATION NAME]. R1 had an NG (nasogastric) tube (a tube that carries food and medicine to the stomach through the nose) placed at the hospital to administer [MEDICATION NAME] and reverse the withdrawal effects. The anonymous complainant alleged the facility did not inform R1's POA or R1's neurologist that R1 at times refused or was unable to take [MEDICATION NAME] as prescribed. On 6/24/19, the Surveyor reviewed R1's medical record. R1 was admitted to the facility with [DIAGNOSES REDACTED]. R1's most recent Quarterly MDS (Minimum Data Set), dated 5/30/19, indicated R1 was severely cognitively impaired and required extensive assistance of staff for ADLs (activities of daily living). R1's ADL Functional/Rehabilitation Potential care plan, dated 4/18/18, stated R1 would continue to achieve the highest practicable level of well-being with administration of medications according to preference/method of best acceptance. The care plan contained interventions to monitor for adverse effects from medications and to crush and co-mingle medications per guidelines to decrease R1's frustration with multiple individual medication administrations. An evaluation note on the care plan, dated 5/19/19, indicated R1 continued to refuse medications at times. R1's Short-Term Memory/Activated POA care plan, dated 3/08/16, contained an intervention to update POA-C and FM (Family Member)-D with all changes and health care decision making needs. R1's face sheet contained the same intervention. The Surveyor reviewed R1's physician orders [REDACTED]. The Surveyor noted R1 refused one dose on 5/19, one dose on 5/23, one dose on 5/25, three doses on 5/31, one dose on 6/01, one dose on 6/03, one dose on 6/05, two doses on 6/08, one dose on 6/11, one dose on 6/12 and three doses on 6/15. A progress note, written by MD (Medical Doctor)-E (R1's neurologist and the MD who prescribed and managed R1's [MEDICATION NAME]) and dated 5/06/19, stated, The patient is to continue [MEDICATION NAME] 25/100, 2-1/2 tablets 3 times a day. (Patient) is doing well in regards to motor symptoms. I have told (FM-D) that (FM-D) should call us if patient gets more worsening of symptoms. A progress note, written by LPN (Licensed Practical Nurse)-F (who worked in MD-E's office) and dated 6/14/19, stated, (NHA (Nursing Home Administrator)-A) calls clinic stating (NHA-A) spoke with (FM-D) regarding increasing Parkinson symptoms. States that (R1) has had some trouble with meal time as (R1) cannot open (R1's) mouth as it seems stiff. Once (R1) does get food in, (R1) is holding it in (R1's) mouth then spitting it out .(R1) is more stiff and rigid in the morning and takes a lot more for patient to wake and get up .(R1's) hands seemed to be more clenched and stiff. Was wondering if possibly medications can be looked at or if antidepressant can be changed to help with appetite and help with (R1's) [MEDICAL CONDITION] symptoms. They feel all symptoms are stemming from [MEDICAL CONDITION] .(MD-E) is out of office until beginning of July. (NHA-A) will discuss with (FM-D) if they want to monitor until (MD-E) returns, be evaluated by (MD-H), or discuss with PCP (Primary Care Provider)-I until (MD-E's) return. (NHA-A) will call back to clinic on (6/27/19) with decision. A progress note, written by LPN-G (who worked in MD-E's office) and dated 6/17/19, stated, Call received from (FM-D) to also report change. Per (FM-D), (R1) is having more rigid movements, pushing head back, and fast/sudden movements. Per (FM-D) .would like to address new concerns with (MD-E) when (MD-E) returns . An ED (emergency department) provider note, written by MD-J and dated 6/17/19, indicated R1 arrived at the hospital via ambulance after R1 was difficult to arouse, displayed an altered mental status and developed a 102.2 F (Fahrenheit) degree fever. R1's left arm and left leg were noted to be rigid and R1's face displayed no motion. The note stated, Late in (patient) course it is revealed (patient) has been without (patient's) [MEDICAL CONDITION] meds. Plan for NG tube and PO (oral) [MEDICAL CONDITION] meds. A consult, written by MD-H and dated 6/17/19, stated, [MEDICAL CONDITION] - severe, in akinetic (slowed or nearly absent body movement) crisis, likely from drug withdrawal. The consult indicated R1 was to receive [MEDICATION NAME] via NG tube. A History and Physical, written by MD-K and dated 6/17/19, stated, Patient has PD ([MEDICAL CONDITION]) and apparently has not been able to take medications properly at (nursing home) since (6/15/19) .Acute metabolic [MEDICAL CONDITION] (abnormalities of the water, electrolytes, vitamins and other chemicals that adversely affect brain function) likely due to a combination of [MEDICAL CONDITION] Hyperpyrexia Syndrome (PHS) and UTI (urinary tract infection). Combination of pyrexia, muscle rigidity, a reduced level of consciousness and autonomic (the nervous system that regulates bodily functions including heart and respiratory rates) instability support PHS and is a neurological emergency. A progress note, written by MD-L and dated 6/21/19, stated, Patient is more awake and alert this morning .Per report, patient has been not taking (patient's) medications and giving (sic) difficulty to eat with poor oral intake. Nasogastric tube currently inserted .restarted on [MEDICATION NAME] .patient is now more awake and alert .Per neurology, can consider Neupro patch (a [MEDICATION NAME] that improves motor functioning and activities of daily living in patients with [MEDICAL CONDITION]). During an interview with the Surveyor on 6/26/19 at 10:40 AM, AC (Anonymous Complainant)-M stated the facility didn't tell POA-C or FM-D that R1 was refusing [MEDICATION NAME]. AC-M indicated an MD at the hospital informed FM-D of the missed doses. During an interview with the Surveyor on 6/26/19 at 12:10 AM, POA-C stated a neurologist at the hospital told POA-C either R1's [MEDICATION NAME] wasn't working or wasn't given. POA-C stated R1 improved after [MEDICATION NAME] was administered in the hospital. POA-C stated POA-C wasn't informed by the facility that R1 either refused or was unable to take multiple doses of [MEDICATION NAME]. POA-C stated, I'm three hours away. (FM-D) is my eyes and ears (in the facility) .(R1) was grumpy about the tube in (R1's) nose .I talked to (DON (Director of Nursing)-B) and (ADON (Assistant Director of Nursing)-N) a long time ago. I made it clear that I wanted to be updated about everything. During a second interview with the Surveyor on 6/26/19 at 2:49 PM, POA-C indicated POA-C told the facility upon R1's admission POA-C wanted to be updated with all orders/changes. POA-C stated, I said I always need to be notified. POA-C indicated since FM-D spent more time in the facility than POA-C, FM-D was often aware of daily occurrences and changes. POA-C stated POA-C told the facility FM-D could be updated on all orders and changes; however, POA-C also wished to be notified by the facility as the facility shouldn't and couldn't rely on FM-D to update POA-C. During an interview with the Surveyor on 6/27/19 at 8:25 AM, FM-D stated, I wasn't told (by the facility) (R1) wasn't taking ([MEDICATION NAME]). I would've taken matters into my own hands. I was told it was hard to get meds in (R1) .things like that .not that (R1) outright wasn't taking them. FM-D stated FM-D was told by an MD at the hospital that (R1) looked like someone who wasn't getting [MEDICAL CONDITION] medication. FM-D stated, You could break (R1's) limbs they were so stiff .the [MEDICAL CONDITION] medication could've been given in a patch form. FM-D also stated the missed [MEDICATION NAME] doses were not addressed in R1's care conference on 6/04/19. During an interview with the Surveyor on 6/26/19 at 3:58 PM, LPN (Licensed Practical Nurse)-G stated MD-E's office wasn't notified R1 wasn't consistently taking [MEDICATION NAME]. LPN-G indicated there was a consultation on 5/06/19, but there was no mention of missed medication. LPN-G indicated [MEDICATION NAME] was imperative and R1 needed the medication. LPN-G stated, We absolutely would've wanted to know that (R1) wasn't taking ([MEDICATION NAME]) as ordered .if it was a swallowing issue, we could've given the med in another form. During an interview with the Surveyor on 7/01/19 at 10:10 AM, LPN-F stated LPN-F spoke with NHA-A on 6/17/19 when NHA-A called MD-E's office. LPN-F stated NHA-A was concerned (R1) wasn't eating or opening (R1's) mouth and exhibited increased [MEDICAL CONDITION] symptoms. LPN-F stated NHA-A didn't mention R1 was refusing [MEDICATION NAME] and stated, I would've consulted with the doctor if that was mentioned. Our office wasn't aware the meds weren't being given. During an interview with the Surveyor on 7/01/19 at 11:10 AM, NHA-A indicated NHA-A spoke with LPN-F on 6/17/19 regarding R1's decreased oral intake. NHA-A stated NHA-A didn't specifically mention medications and stated, I just said we're having a hard time getting anything into (R1) orally . During an interview with the Surveyor on 7/01/19 at 12:20 PM, DON-B stated DON-B didn't speak with MD-E's office regarding R1's refusal of [MEDICATION NAME]. When asked if DON-B informed POA-C regarding R1's [MEDICATION NAME] refusals, DON-B stated DON-B did not inform POA-C. When asked if DON-B informed FM-D about R1's [MEDICATION NAME] refusals, DON-B stated DON-B didn't specifically inform FM-D about R1's refusals, but was under the impression FM-D knew as FM-D was aware R1 was having a difficult time with oral intake.

Based on observation, record review and staff interviews, the facility did not ensure 1 resident (R) (R283) of 18 sampled residents received reasonable accommodation of needs. Multiple observations were made of R283 sitting at an angle in a wheelchair with left side forward, left foot on floor and right foot dangling, unsupported. Finding include: On 06/19/18 at 03:53 PM, during interview with R283, the Surveyor observed the resident sitting in a wheelchair at an angle with the resident's left hip forward without a foot pedal on the wheelchair. R283's left foot was resting on the floor and right foot was dangling unsupported. R283 indicated, I can't touch both feet on the floor unless I slide myself forward. On 06/20/18 at 01:02 PM, the Surveyor observed R283 sitting in the wheelchair at an angle with the resident's left hip forward without a foot pedal on the wheelchair. R283's left foot was resting on the floor and right foot was dangling unsupported. On 06/21/18 at 10:42 AM, the Surveyor observed R283 sitting in a wheelchair with both feet supported by foot pedal. The Surveyor interviewed CNA (Certified Nursing Assistant)-D, who indicated R283 usually does not have foot pedals on the wheelchair unless leaving the facility. CNA-D indicated R283 was going on a home visit. On 6/21/18 at 10:44 AM, the Surveyor interviewed R283, who indicated, Whenever I leave the facility I have to have my foot pedals on my wheelchair, I don't use them (foot pedal) unless I leave. On 06/21/18 at 01:21 PM, the Surveyor interviewed OTA (Occupational Therapy Assistant)-C regarding R283. OTA-C indicated whenever OTA-C works with R283, the foot pedals are on the wheelchair and if they (foot pedals) are not on, OTA-C puts them on. OTA-C indicated if working with strengthening the resident's core, OTA-C wants R293's feet on the floor so the resident sits forward and feet are on the floor. OTA-C indicated R283 needs a wheelchair so the resident's feet touch the floor. On 06/26/18 at 09:24 AM, the Surveyor interviewed OTA-C regarding R283. OTA-C indicated maintenance came and adjusted R283 to hemi-height wheelchair. OTA-C verified R283 had been sitting twisted to the left side and the resident's right foot was unsupported. OTA-C indicated R283 should have been evaluated for wheelchair positioning and R283's wheelchair should have been adapted. OTA-C further indicated improper positioning in the wheelchair put R283 at risk for falling, sliding forward, increased swelling, skin breakdown and possible re-injury to the resident's leg. OTA-C also indicated supporting the resident's feet is important to prevent foot drop. On 06/26/18 at 10:37 AM, the Surveyor interviewed DOR (Director of Rehab)-E regarding R283. DOR-E verified resident was incorrectly positioned in a wheelchair that was too high for the resident's feet to reach the floor should have foot pedals. DOR-E further indicated if the resident self- propels their wheelchair, their feet should rest on floor to prevent foot drop. DOR-E stated improper wheelchair positioning increases the risk of skin breakdown related to shearing, increases risk for falls and/or injury.

Based on staff interviews and record review, the facility did not ensure possible misappropriated narcotics were reported within 24 hours of discovery to the State Survey Agency and law enforcement for 2 residents (R) (R7 and R61) of 4 vulnerable residents with [MEDICATION NAME]es (a schedule II controlled prescription narcotic synthetic opioid). R7's [MEDICATION NAME] was discovered missing on 6/1/17. The facility thoroughly searched and was unable to locate R7's [MEDICATION NAME]. The facility did not identify the missing narcotic patch as a possible misappropriation (drug diversion) and did not report the incident to the State Survey Agency or law enforcement. R61's [MEDICATION NAME] was discovered missing during a night shift which began on 6/13/18 at 10:30 PM. Staff did not immediately report the missing [MEDICATION NAME] to the Nursing Home Administrator (NHA) or designee. The facility thoroughly searched and was unable to locate R61's [MEDICATION NAME]. The facility did not report the possible misappropriation to the State Survey Agency. The facility reported the incident to local law enforcement more than 24 hours after discovery. Findings include: Facility policy titled Abuse Prohibition, revision dated 11/23/16, documents, The Administrator / or designee will immediately report all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, exploitation and misappropriation of resident property to the DQA (Division of Quality Assurance). Immediate, as defined by CMS (Centers for Medicare and Medicaid Services), to be as soon as possible but not to exceed 24 hours after discovery of the incident . If necessary, law enforcement will be notified. 1. On 6/19/18, the Surveyor reviewed R7's medical record and noted an order, dated 6/1/18, to replace R7's [MEDICATION NAME] as previous patch was unable to be located. Order to reschedule as appropriate (change every 72 hours). R7's progress notes did not include information regarding the missing [MEDICATION NAME]. On 6/21/18, the facility provided the survey team with an investigation summary regarding R7's [MEDICATION NAME] incident dated 6/1/18. On 6/21/18 at 10:41 AM, during an interview with the Surveyor, Director of Nursing (DON)-A revealed there was a second investigation into a missing [MEDICATION NAME] and that patch was never located. On 6/21/18 at 12:27 PM, during an interview with the Surveyor, Interim Nursing Home Administrator (NHA)-B verified R7's [MEDICATION NAME] had never been located. NHA-B explained the facility did not report the incident to the State Survey Agency or law enforcement because R7 was assessed and not in pain so there was no negative outcome. NHA-B indicated the facility addressed it immediately and added an intervention of putting [MEDICATION NAME] (a transparent medical dressing) over the top of the [MEDICATION NAME]. 2. On 6/21/18, the facility provided an investigation summary for R61's [MEDICATION NAME] incident dated 6/13/18. The Surveyor noted the following regarding the investigation summary: ~ A timeline when the night shift Licensed Practical Nurse (LPN) actually discovered the [MEDICATION NAME] missing ~ DON-A and NHA-B were not notified until the day shift hours of 6/14/18 ~ The time NHA-B was notified ~ Police were not notified until 6/15/18 On 6/21/18 at 12:30 PM, the Surveyor interviewed DON-A and NHA-B together. DON-A verified staff education was provided regarding reporting immediately when unable to locate a controlled substance. NHA-B indicated became aware of the incident on 6/14/18, when NHA-B came into work between 7:00 AM and 8:00 AM. DON-A verified the details of when the night LPN discovered the missing patch were not documented in the summary and stated, I want to say it was in the middle of the shift. (The LPN) starts at 10:30 PM. NHA-B explained the incident was not reported to the State Survey Agency because there was no negative outcome for R61. NHA-B indicated the facility changed processes to do more frequent placement checks and require two staff after the second incident. NHA-B indicated did not consider the incident reportable because the facility completed a thorough investigation and no particular suspect was identified. NHA-B further explained R61's missing [MEDICATION NAME] was reported to the police because the facility wanted a different presence in the building so staff would know we take this seriously. NHA-B verified drug diversion was a possible cause and verified the incidents occurred within a two week period. DON-A commented the law enforcement had been contacted so staff would know, We were doing a thorough investigation. On 6/21/18 at 12:56 PM, NHA-B informed the Surveyor the facility looked at staff schedules but didn't include that information in the investigation summary.

Based on record review, resident and staff interviews, the facility did not promptly resolve grievances for 1 (R (Resident) 5) of 19 sampled residents reviewed for grievances. R5's family member reported a missing clothing item after the clothing was sent to the facility's laundry to be laundered. The facility did not have evidence of the steps taken to resolve R5's missing shirt or follow up with the family member that voiced the concern of R5's missing shirt. Findings include: The facility policy Filing Grievances/Complaints, revised November 2016, indicated: Policy Statement: Our facility will help residents, their representatives (sponsors), other interested family members, or resident advocates file grievances or complaints without fear of discrimination or reprisal when such requests are made. Policy Interpretation and Implementation 1. Any resident .or .family member .may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of discrimination or reprisal in any form. 2. Upon admission, residents are provided with written information on how to file a grievance or complaint. A copy of our grievance/complaint procedures is posted. 3. Grievances and/or complaints may be submitted orally or in writing. 4. The administrator has been designated as the grievance officer of the facility. 5. Upon receipt of a grievance and/or complaint, Director of Social Services or designee will investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. 6. The Administrator will review findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. 7. The resident, or person filing the grievance and /or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The Administrator, or his or her designee, will ensure resolution of the grievance and ensure appropriate follow up has been completed . Beginning 4/18/17, the Surveyor reviewed R5's medical record. The resident's 1/21/17 face sheet listed multiple [DIAGNOSES REDACTED]. R5's MDS (Minimum Data Set) assessment dated [DATE], documented the resident's cognition was severely impaired and the resident relied on staff for extensive assistance with dressing, hygiene and activities of daily living. On 4/19/17 at 12:50 p.m., the Surveyor conducted a routine interview with FM (Family Member)-E, who reported an unresolved grievance. FM-E reported making the facility aware of R5's pink thermal shirt, part of a set, that had gone missing after the outfit was sent to the facility's laundry. FM-E stated had reported the missing shirt to the NHA (Nursing Home Administrator) and laundry staff, who indicated the pink shirt was not in the laundry. On 4/20/17 at 8:55 a.m., the Surveyor interviewed LA (Laundry Aide)-L regarding a handwritten note that was observed posted on the laundry area wall which read: (R5) missing long sleeve hot pink thermal shirt with heart on front. LA-L indicated she first saw the above note the previous Tuesday, on 4/11/17. LA-L stated the laundry supervisor usually follows up on missing items. On 4/20/17 at 9:05 a.m., Surveyor interviewed NHA (Nursing Home Administrator)-F, who verified was aware of R5's missing clothing item. NHA-F indicated a Missing item Form gets filled out when the facility is made aware an item is missing. On 4/20/17 at 12:20 p.m., NHA-F and the Surveyor reviewed the Missing Item Form indicating R5 was missing clothing. NHA-F verified this form had just been filled out on 4/20/17, and staff should have completed the form when notified of the missing clothing. NHA-F indicated blank Missing item Forms would be located in the laundry and staff were receiving education on how to fill out the forms and that they are to initiate an investigation as soon as they are aware of a missing item. On 4/24/17 at 1:45 p.m., the Surveyor interviewed LA (Laundry Aide)-K, who confirmed writing the note after FM (Family Member)-M reported R5 was missing a shirt on 4/10/17. LA-K stated I wrote the note and stuck it on the wall. I knew I wouldn't be here the next day. LA-K indicated we just kept an eye out (for the missing item) when putting clothing away.

Based on observation, staff interviews and record review, the facility did not ensure 3 (R (Resident) 3, R15 and R14) of 12 sampled members observed during the provision of incontinence care received appropriate treatment and services to prevent urinary tract infections. R3 was not provided complete perineal care after an episode of bowel incontinence. In addition, R3's urinary catheter drainage bag was lifted above the level of the resident's bladder. During the provision of care, staff lifted R15's urinary catheter drainage bag above the level of the resident's bladder. R14 did not receive thorough perineal/catheter care. In addition, staff lifted R14's urinary catheter drainage bag above the level of the resident's bladder. Findings include: Facility's policy Catheter Care, Urinary, revised date 9/2005; General Guidelines 4. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Steps in the Procedure 5. Put on gloves 7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry. 8. Pour wash water down commode. Flush commode. 9. Place soiled linen into designated container. 10. Put on clean gloves. 11. Remove gloves and discard the designated container. Wash and dry your hands thoroughly. 12. Provide privacy. Cover the resident with a sheet, exposing only the perineal area. 13. With nondominant hand separate the labia of the female resident or retract the foreskin of the uncircumcised male resident. Maintain the position of this hand throughout the procedure. 14. Assess the urethral meatus. 15. For the female: Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. Do not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water using the above technique. For the male: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular stroke from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. 16. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. According to Lippincott's Textbook for Nursing Assistants 3rd edition published in 2012, proper perineal care helps to prevent skin breakdown, pressure ulcers, infection and odor. The standard also directs staff to provide thorough incontinent cares by cleansing all potentially contaminated areas including the rectum and buttocks. According to in the article entitled, Indwelling Catheter Management: From Habit-based to Evidence-based Practice, Drainage bags are designed with either an anti-reflux valve or anti-reflux chamber to prevent reflux of contaminated urine from the bag into the tubing. Drainage bags should be positioned below the level of the patient's bladder. Transporting patients with drainage bags positioned on the patients abdomens or between their legs should be avoided (Ostomy Wound Management, 2003). 1. Beginning 4/18/17, the Surveyor reviewed R3's medical record. The 1/2/17 MDS (Minimum Data Set) assessment dated [DATE], documented R3's [DIAGNOSES REDACTED]. Physician orders, dated 11/5/16, indicated R3 had a history of [REDACTED]. On 4/20/17 at 7:33 a.m., the Surveyor observed CNA (Certified Nursing Assistant)-J and CNA-I transfer R3 using a sit-to-stand mechanical lift. The CNAs attached R3's urinary catheter drainage bag to the mechanical lift above the level of the resident's bladder. As the CNAs lifted R3 to a standing position from the recliner, and the catheter drainage bag remained positioned above the level of R3's bladder. LPN (Licensed Practical Nurse)-G then lowered R3's brief and pants to observe the resident's coccyx wound and confirmed R3 had been incontinent of stool. At that time, LPN-G began to cleanse stool from the resident's posterior perineal area and was transferred to sit on the toilet. After R3 was finished using the toilet, R3 was again lifted with the mechanical lift to a standing position. While wearing gloves and using disposable wipes, CNA-I cleansed R3's posterior perineal area only. LPN-G then placed a medicated (TUCKS) pad on the resident's anal area and CNA-J pulled up R3's brief and pants, and R3 was transferred back to sit in the recliner. At 7:48 a.m., following the observation, the Surveyor interviewed LPN-G regarding R3's care. LPN-G confirmed the above observations and verified R3's frontal perineal area and catheter were not thoroughly cleansed and should have been. In addition, LPN-G verified the location of R3's urinary catheter drainage bag was above the level of the resident's bladder and was positioned too high, as this could force urine to back flow and cause a urinary tract infection. On 4/24/17 at 12:00 p.m., Surveyor interviewed DON (Director of Nursing)-A regarding the observation of care with R3. DON-A confirmed when performing perineal care on a resident with a catheter, after stool incontinence, staff are to cleanse the frontal perineal area first, around meatus and catheter tubing, then cleanse posterior perineal area. 2. Beginning 4/20/17, the Surveyor reviewed R15's medical record. The resident's Face Sheet dated 2/1/17 documented multiple [DIAGNOSES REDACTED]. R15's MDS assessment documented the resident utilized a urinary catheter and required an extensive amount of assistance from staff for hygiene, toileting and activities of daily living. The BIMS score was 8 out of 15, indicating the resident's cognition was impaired. On 4/24/17 at 11:45 a.m., the Surveyor observed CNA-H provide care to R15, who was being transferred into a wheelchair with a mechanical sit-to-stand lift. CNA-H removed R15's catheter drainage bag from it's location on the lift and raised the bag to the CNA's eye level to observe the amount of urine in the drainage bag. The Surveyor observed the urine flowing backwards in the tubing while the bag was elevated. CNA-H returned the bag to a level below R15's bladder. Following the observation, at 11:57 a.m., the Surveyor interviewed CNA-H, who confirmed lifting the urinary drainage bag above the level of R15's bladder and verified the facility's practice indicated catheter bags should not be elevated above the level of the resident's bladder. On 4/24/17 at 12:00 p.m., the Surveyor interviewed DON (Director of Nursing)-A, who confirmed catheter bags are not to be lifted above the level of the resident's bladder. 3. On 4/18/17, the Surveyor reviewed the medical record of R14, whose [DIAGNOSES REDACTED]. R14's record included documentation the resident had a history of [REDACTED]. R14's most recent MDS assessment dated [DATE], documented the resident required extensive assistance of staff for bed mobility, transfers, toileting and activities of daily living. The MDS assessment indicated R14 had an indwelling Foley catheter. On 4/20/17 at 10:00 a.m., the Surveyor observed CNA-D provide catheter care for R14, who was lying in bed. With cleansed and gloved hands, CNA-D used the same washcloth to cleanse under R14's arms, chest, underneath breasts, abdominal region, groin folds, labia from front to back and then the catheter tubing from insertion site approximately 5 inches downward. Without removing gloves, CNA-D rinsed and dried R14 in the same manner as written above. While wearing the same soiled gloves, CNA-D applied lotion to R14's arms, chest, torso, groin fold and legs and feet. CNA-D removed gloves, sanitized hands and provided posterior cares for R14. With cleansed and gloved hands, CNA-D dressed R14's upper body and then lifted R14's urinary drainage bag above the level of R14's bladder three times while assisting R14 with dressing the resident's lower body. Immediately following the above observation, the Surveyor interviewed CNA-D regarding the observation. CNA-D indicated it was facility policy to thoroughly cleanse the resident with a clean portion of the washcloth with each cleansing stroke. CNA-D verified using one washcloth to cleanse R14's entire armpits, torso, perineal area and the catheter's draining tubing. CNA-D verified the washcloth surface was not clean while cleansing the perineal area and the catheter's drainage tubing. CNA-D also verified not removing soiled gloves and cleansing hands between tasks. CNA-D indicated it was facility policy to keep the urinary drainage bag below the level of the resident's bladder at all times. CNA-D indicated being unaware the urinary drainage bag was above the level of the resident's bladder while assisting with dressing. On 4/24/17 at 10:00 a.m., the Surveyor interviewed DON (Director of Nursing)-A regarding perineal and catheter care. DON-A indicated employees should follow the facility policy and procedure for perineal and catheter cares and indicated it is the facility's policy to keep the catheter drainage bag below the level of the resident's bladder at all times.

Based on observation, record review and staff interview, the facility did not ensure that it is free of medication error rates of 5 percent or greater. During the medication pass, 2 errors out of 30 opportunities which affected 2 (R (Resident) 20 and R21) of 9 sampled residents observed. The errors resulted in an error rate of 6.6%. R20 had a physician's orders [REDACTED]. The resident was not encouraged or instructed the proper technique while self-administering the inhaler. R21 had a physician's orders [REDACTED]. R21 received 20 ml of liquid [MEDICATION NAME], 500 mg/15 ml. Findings: The facility's Administering Medications policy, revised date 12/20/12 states: Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. The licensed nurse shall follow the five Rights for medication pass.: Right Resident, Right Medication, Right Time, Right Dose, Right Route. 5. The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time and right method (route) of administration before giving the medication. Boehringer [MEDICATION NAME] Pharmaceuticals, Inc., the manufacturer of [MEDICATION NAME] Respimat, in a package insert last updated 5/16, indicated, Two puffs from [MEDICATION NAME] Respimat equals one dose of the medication .While taking in a slow, deep breath through your mouth, press the dose release button and continue to breathe in slowly for a as long as you can. Hold your breath for 10 seconds, Repeat steps A. and B. so that you get the full dose. 1. On 4/19/17 at 8:15 a.m., the Surveyor observed LPN (Licensed Practical Nurse)-C prepare and administer medications for R20. [MEDICATION NAME] Respimat 2.5 mcg (micrograms) was presented to the resident who was instructed by LPN-C to To take a deep breath. The resident was noted to take one inhalation and returned the canister to LPN-C. No further instructions were offered by LPN-C. Immediately following the above observation, the Surveyor interviewed LPN-C regarding the observation with R20. LPN-C verified R20 took one inhalation and no instructions were given to take another inhalation. LPN-C further indicated the physician's orders [REDACTED]. LPN-C added, To make sure they get all the powder out of the capsule. 2. On 4/18/17 at 4:35 p.m., the Surveyor observed LPN-B prepare medications to be administered to R21. 20 ml of [MEDICATION NAME] liquid, 160 mg/5 ml was measured and mixed into 120 ml of Med Pass (high calorie/protein supplement) and administered to R21. On 4/18/17 at 5:20 p.m., the Surveyor interviewed LPN-B regarding R21's medication administration. LPN-B verified the [MEDICATION NAME] given to R21 was not the correct dose as prescribed by the physician.

Based on observation, staff interview and record review, the facility did not maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection related to hand hygiene involving 2 (R (Resident) 3 and R14) of 15 residents observed receiving personal and wound cares. LPN Licensed Practical Nurse)-G cleansed stool from R3, did not remove gloves or sanitize hands and touched R3's brief and pants with the same soiled gloves. During provision of morning and catheter cares, CNA (Certified Nursing Assistant)-D did not remove gloves and/or sanitize hands in accordance with facility policy and procedures. Findings include: Facility's policy; Handwashing/Hand Hygiene, revised date 4/21/13 Policy Statement:This facility considers hand hygiene the primary means to prevent the spread of infections. 5. Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: b. When hands are visibly soiled (hand washing with soap and water); c. Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); h. Before and after assisting a resident with personal care (e.g., oral care, bathing); k. Before and after changing a dressing; l. Upon and after coming in contact with a resident's intact skin . n. Before and after assisting a resident with toileting (hand washing with soap and water); q. After contact with a resident's mucous membranes and body fluids or excretions; r. After handling soiled or used linens, dressings, bedpans, catheters and urinals; u. After removing gloves or aprons; The Morbidity and Mortality Weekly Report dated 10/25/02 and published by the Centers for Disease Control and Prevention entitled, Guideline for Hand Hygiene in Health Care Settings indicated recommendations to wash hands after removing gloves and to decontaminate hands after contact with body fluids or excretions and when moving from a contaminated body site to a clean body site during patient care. 1. Surveyor reviewed R3's medical record beginning 4/18/17. The following documentation was noted: ~ MDS (Minimum Data Set) assessment dated [DATE], listed multiple [DIAGNOSES REDACTED]. ~ Physician orders [REDACTED]. ~ Progress notes dated 4/11/17, indicating has an open wound to the coccyx. On 4/20/17 at 7:33 a.m., the Surveyor observed LPN (Licensed Practical Nurse)-G lower R3's brief and pants to observe the resident's coccyx wound and confirmed R3 had been incontinent of stool. At that time, LPN-G began to cleanse stool from the resident's posterior perineal area reaching between the resident's legs from behind, wiping front-to-back, with gloved hands and prepackaged wipes. After removing a large amount of soft stool with the wipes, LPN-G discarded the wipes. With the same gloves, LPN-G touched R3 and the resident's brief and pants before discarding gloves and sanitizing hands. On 4/20/17 at 7:57 a.m., the Surveyor interviewed LPN-G regarding the observation with R3. LPN-G stated I should have discarded gloves and sanitized hands before touching the resident, brief and pants. On 4/24/17 at 12:00 p.m., the Surveyor interviewed DON (Director of Nursing)-A, who confirmed staff are expected to remove soiled gloves and sanitize hands after contaminating with stool and before touching residents and clean items in the room. 2. On 4/20/17 at 10:00 a.m., the Surveyor observed CNA-D provide morning and catheter care for R14, who was lying in bed. With cleansed and gloved hands, CNA-D used the same washcloth to cleanse under R14's arms, chest, underneath breasts, abdominal region, groin folds, labia from front to back and then the catheter tubing from insertion site approximately 5 inches downward. Without removing gloves, CNA-D rinsed and dried R14 in the same manner as written above. While wearing the same soiled gloves, CNA-D applied lotion to R14's arms, chest, torso, groin fold and legs and feet. CNA-D then removed gloves, sanitized hands and continued to provide care for R14. Immediately following the above observation, the Surveyor interviewed CNA-D regarding the observation. CNA-D indicated it was facility policy to thoroughly cleanse the resident with a clean portion of the washcloth with each cleansing stroke. CNA-D verified using one washcloth to cleanse R14's entire armpits, torso, perineal area and the catheter's draining tubing. CNA-D verified the washcloth surface was not clean while cleansing the perineal area and the catheter's drainage tubing. CNA-D also verified not removing soiled gloves and cleansing hands between tasks.

Based on observation, staff interviews, and record review, the facility did not ensure food was stored, prepared and served under sanitary conditions. ~ Cooking temperatures not monitored on a routine basis. ~ Open undated beverages with 1 undated opened beverage past the manufacturer's expiration date. ~ Cleaning clothes not stored in cleansing solution when not in use. These practices had the potential to effect all 94 residents residing in the facility at the time of survey. Findings include: On 2/15/16 at 8:28 a.m., during the initial tour of the kitchen, ADM (Assistant Dietary Manager)-G and RD/DM (Registered Dietician/Dietary Manager)-H informed surveyor # the facility utilized the WI (Wisconsin) Food Code as its standard of practice. COOKING TEMPERATURES WI Food Code 2013 2-103.11 documents The person in charge shall ensure that: (F) Employees are properly cooking potentially hazardous food (time/temperature control for safety food), being particularly careful in cooking those foods known to cause severe foodborne illness and death, such as eggs and comminuted meats, through daily oversight of the employees' routine monitoring of the cooking temperatures using appropriate temperature measuring devices properly scaled and calibrated as specified under 4-203.11 and 4-502.11(B). On 2/15/16 at 10:38 a.m., surveyor # observed DC (Dietary Cook)-I preparing food for the resident's lunch meal service. Lunch meal items included noodles, minute steaks, broccoli, ham, mixed vegetables and mashed potatoes. At 10:42 a.m., DC-I removed minute steaks from the oven and without checking for proper cooking temperature, placed the minute steaks in the steam table. Surveyor # noted staff started to place the food items on the steam table 53 minutes prior to the scheduled 11:35 a.m., resident lunch meal service. The surveyor observed staff remove each menu food item from its cooking source without monitoring the food item's cooking temperature. At 11:23 a.m., surveyor # interviewed RD/DM-H regarding cooking temperatures. RD/DM-H verified the cooking temperatures of the food items were not taken prior to the food items being placed in the steam table. RD/DM-H stated the Facility's practice was to have staff take the food item's temperature once the food item was placed in the steam table, to check the food item's hot holding temperature. RD/DM-H stated the food items would be reheated as needed, if the food item's temperature was not up to temperature on the steam table. RD/DM-H verified the facility did not document any cooking temperatures. RD/DM-H verified fish must reach a cooking temperature of 145 degrees F and other meats must cook to higher temperatures. OPEN, UNDATED BEVERAGES WI Food Code 2013 3-501.17(B) documents Except as specified in paragraphs (D) to (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and, if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in paragraph (A) of this section and; (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. On 2/15/16 at 10:56 a.m., surveyor # observed 2 carts with beverages prepared for the resident lunch meal service and noted the following: ~ 1 opened quart container of Half & Half, without an open date. The manufacturer's expiration date was 2/12/16. ~ 1 opened quart container of Half & Half, without an open date. ~ 1 opened quart container of Silk Soymilk, without an open date. The manufacturer's notation on the exterior of the container documents use within 7-10 days of opening. ~ 1 opened 48 ounce Thick & Easy Nectar consistency lemon flavor drink, without an open date. The manufacturer had a statement on the exterior of the container stating use within 10 days of opening. ~ 1 opened 48 ounce Thick and Easy honey consistency apple juice without an open date. The manufacturer had a statement on the exterior of the container stating use within 10 days of opening. At that time, surveyor # interviewed RD/DM-H who verified the beverages listed above and located on the beverage carts for the resident's lunch meal service, did not have open dates to indicate when those beverages should be discarded. RD/DM-H stated the Half & Half, Silk Soymilk and Thick & Easy beverages were not items that were consumed within 24 hours of opening. RD/DM-H verified open beverages should have a use by date marked on the container at the time of opening. RD/DM-H stated an in-service regarding dating practices had taken place within the last month. On 2/15/16 at 12:18 p.m., surveyor # and RD/DM-H observed an open, undated 48 oz Thick and Easy Nectar consistency apple juice in the 400 unit's food service refrigerator. RD/DM-H verified the open beverage container should be marked with a use by date. CLEANING CLOTHS WI Food Code 2013 3-304.14(B) documents cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under 4-501.114. On 2/15/16 at 8:28 a.m., surveyor # began initial tour of the facility's main kitchen and observed 2 soiled cleaning cloths, not in use and lying on food preparation surfaces. At 8:44 a.m., surveyor # interviewed RD/DM-H regarding the storage of the cleaning cloths between uses. RD/DM-H verified the cleansing clothes should have been in a bucket of solution between uses. On 2/15/16 at 12:55 p.m., surveyor # entered the facility's mechanical dishwashing room and observed a soiled cleaning cloth lying on the back ledge of the handwashing sink in the same room. At that time, surveyor # interviewed DC-J regarding the cleansing cloth. DC-J stated the cloth had been in that location for approximately 30 minutes. DC-J verified the cleaning cloth should be stored in a bucket of solution and at that time, removed the cleaning cloth from the handwashing sink.

Based on record review, staff, resident and resident advocate interviews, the facility did not make prompt efforts to resolve grievances for 3 (resident #21, #8 and #5) of 20 sampled and supplemental sampled residents reviewed. Resident #21 voiced a concern to staff in December 2015, that their watch had been missing. The facility staff did not fill out a missing item form that would be distributed to all departments to assist and attempt to locate resident #21's missing watch. Additionally, the facility did not follow-up with resident #21 to ensure the concern had been resolved. RA (Resident advocate)-D voiced a concern to staff in December 2015, that resident #8's soiled clothing had been placed and left on the couch in resident #8's room daily. The facility staff did not initiate a Resident Grievance/Complaint Investigation Report Form, when RA-D reported the concern of soiled clothing, per their policy and procedure to ensure RA-D's concern was resolved and follow-up was completed. RA (Resident Advocate)-N voiced a concern to staff on 7/14/15, that resident #5 was not receiving oral care twice a day. The facility staff did not initiate a Resident Grievance/Complaint Investigation Report Form, when RA-N reported the concern that resident was not receiving oral care twice a day, per their policy and procedure to ensure RA-N's concern was resolved and follow-up was completed. Findings include: The Facility's policy and procedure titled, Filing Grievances/Complaints, with a revised date of May 2015, indicated, Our facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filling grievances or complaints when such requests are made .1. Any resident, his or her representative, family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form .3. Grievances and/or complaints may be submitted orally or in writing. 4. Upon receipt of grievance and/or complaint, the appropriate manager will investigate the allegations and report such findings to the administrator within five working days of receiving the grievance and/or complaint. 5. The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. 6. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. 7. Grievances will be reviewed at the QAA (Quality Assurance)meeting to identify any treads to be addressed. 1. On 2/15/16, surveyor # reviewed resident #21's medical record. Resident #21's most current MDS (Minimum Data Set) assessment dated [DATE], documented the resident had scored a 15 out of a possible 15 on the cognition assessment (the higher the score, the more cognizant). On 2/15/16 at 10:00 a.m., surveyors # and # conducted the resident group interview. Resident #21 stated, My watch went missing a few months ago. I told facility staff, but I've never heard anything. On 2/15/16 at 2:30 p.m., surveyor # interviewed NHA (Nursing Home Administrator)-A regarding resident #21's missing watch. NHA-A stated, I don't know anything about the missing watch .I will look into it. On 2/16/16 at 11:00 a.m., NHA-A provided surveyor # with a Missing Item Form for resident #21. The form noted, around Christmas time resident #21 was missing a men's Silver Seiko watch (that was resident #21's husbands). The form indicated the watch had been placed on resident #21's inventory list, and housekeeping/laundry had been notified. Surveyor # noted the form had been signed and completed by NHA-A on 2/16/16. Surveyor # interviewed NHA-A regarding the missing item form dated 2/16/16. NHA-A stated, after it was brought to my attention by the survey team, I talked to HSKS (Housekeeping Supervisor)-M regarding the watch. HSKS-M had a note on her desk regarding resident #21's missing watch .I then filled out the Missing Item Form today. NHA-A stated, I did not receive any information verbally or in writing regarding the watch. Staff should have initiated a Missing Item Form when the watch was reported missing, and copies of the form should have been distributed to all departments. The form would initiate a search of the item and ensure follow-up or resolution. NHA-A verified resident #21 had not been updated on if the watch was found or if the concern brought forward had any resolution. NHA-A stated, I did follow-up with resident #21 and resident #21's son regarding the missing watch today. 2. On 2/15/16, surveyor # reviewed resident #8's medical record. Resident #8's most current MDS assessment dated [DATE], documented the resident had scored a 15 out of a possible 15 on the cognition assessment. On 2/15/16 at 12:30 p.m., RA-D informed surveyor # resident #8's soiled clothing is placed and left on the couch in the resident's room every day. RA-D indicated she visits with resident #8 daily in the resident's room. RA-D stated, in December 2015, I had ADON (Assistant Director of Nursing)-C come down to resident #8's room. I complained to ADON-C and had her look at the soiled clothing laying on resident #8's couch. ADON-C informed me she would take care of it, but it continues to happen everyday .the facility never took care of it. On 2/15/16 at 12:50 p.m., surveyor # interviewed resident #8 regarding soiled clothing placed and left on the couch in the resident's room. Resident #8 stated, I have a lot of visitors throughout the week, and the only place in my room visitors can sit down is on the couch. It bothers me when staff leave my dirty cloths on the couch. My dirty cloths should be placed in the basket. On 2/15/16 at 2:00 p.m., surveyor # interviewed ADON-C regarding the concern of soiled clothing left on resident #8's couch. ADON-C verified RA-D brought the above concern to her attention sometime in December 2015. ADON-C informed surveyor # resident #8's care card, that is utilized by direct care staff, was updated in December 2015. ADON-C indicated, Resident #8's care card included instructions for staff to place wet or soiled cloths in a hamper and the PM shift staff to place cloths in the laundry every night per family request. ADON-C indicated the above information was placed on resident #8's care card sometime in December 2015, after receiving RA-D's concern. ADON-C stated, the facility switched to a condensed version of resident care cards four to five weeks ago .Somehow the information from resident #8's old care card was never transferred over to resident #8's new care card. ADON-C then stated, I will place the information on the communication board today. On 2/15/16 at 3:30 p.m., ADON-C informed surveyor # , I talked to NHA-A regarding the concern from RA-D. A Resident Grievance/Complaint Investigation Report Form was not completed when RA-D voiced the above concern. On 2/16/16 at 11:10 a.m., surveyor # interviewed NHA-A regarding the concern made by RA-D regarding resident #8's soiled clothing. NHA-A stated, staff should have initiated a Resident Grievance/Complaint Investigation Report Form, when RA-D reported the concern. The form would have ensured RA-D's concern was resolved and follow-up was completed. 3. On 2/15/16, surveyor # reviewed resident #5's medical record. A progress note entry dated 7/14/16, documented RA-N voiced a complaint that resident #5 wasn't receiving oral care twice a day. The documentation indicated RA-N was concerned that resident #5's mouth had lots of food particles on the resident's teeth and the tongue was coated. The progress note further documented, will place information on 24 hour sheet to monitor when resident #5 is allowing staff to complete oral care and oral care to be completed BID (twice a day). On 2/17/16 at 8:50 a.m., surveyor # interviewed RN/MDSC (Registered Nurse/Minimum Data Set Coordinator)-E regarding resident #5. RN/MDSC-E indicated remembering following up on the concern right away by updating resident #5's plan of care. RN/MDSC-E indicated no complaint form/ paper work had been filled out and no investigation was completed. On 2/17/16 at 1:15 p.m., surveyor # interviewed RN/MDSC-E regarding resident #5. RN/MDSC-E indicated should have filled out a complaint form and should have investigated the complaint. RN/MDSC-E indicated no documentation was found on the 24 hour report related to RA-N's complaint and resident #5 was not monitored to ensure oral care was provided twice a day.

Based on staff interview and record review, the facility did not ensure that a PASRR (Pre-Admission Screen and Resident Review) screen was completed for 1 (Resident #8) of 19 sampled residents. Resident #8 did not receive a Level II PASRR screen based on the requirements of the Level I screen. Findings include: Surveyor # reviewed resident #8's medical record on 2/16/16. Resident #8's face sheet dated 12/16/15, indicated the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The medical record included a PASRR Level I screen form which was completed by the facility on 1/6/15. The form had the box checked that indicated resident #8 was suspected of having a serious mental illness. In Section A, the boxes were checked indicating resident #8 had a current [DIAGNOSES REDACTED]. In Section B, the box was checked indicating a 30 day Maximum Hospital Discharge Exemption. Additional directions on the PASRR form stated, if, during the short-term stay, it is established that the person will be staying for a longer period of time than permitted above, (30 day exemption) the person must be referred for a Level II screen on or before the last day of the permitted time period. Resident #8's medical record did not include documentation that the required Level II PASRR screen had been completed. On 2/16/16 at 1:00 p.m., surveyor # interviewed SW (Social Worker)-F regarding resident #8's PASRR level II screen. SW-F verified the Level II PASRR screen was not completed and stated yes there should be a Level II screen .it was missed.