Every finding on record at Ridgeview Terrace Long Term Care

Based on interview and record review, the facility did not complete the Minimum Data Set (MDS) assessments in the required time frames for 1 of 1 supplemental resident (R10) reviewed for MDS assessments. The facility did not complete R10's admission Comprehensive MDS assessment and Annual Comprehensive assessment in a timely manner. Findings include: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025, indicates: Required MDS records include: Admission, Quarterly, Annual, and Discharge assessments and Entry Tracking records . For the admission assessment, the MDS Completion Date must be no later than 13 days after the Entry Date. For the Annual assessment, the CAA Completion Date must be no later than 14 days after the ARD.R10 admitted to the facility on [DATE]. R10's admission Comprehensive MDS assessment has an ARD of 5/30/25. R10's admission Comprehensive MDS assessment has a completion date of 7/3/25. Of note, this is greater than 13 days. R10's Annual Comprehensive MDS assessment has an ARD of 5/19/26. R10's Annual Comprehensive MDS assessment has a completion date of 6/3/26. Of note, this is greater than 14 days. On 7/8/26 at 2:45 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she is responsible for the completion of the MDS assessments. DON B indicated the assessments were completed late.

Based on interview and record review, the facility did not transmit the Minimum Data Set (MDS) assessments in the required time frames for 1 of 1 supplemental resident (R10) reviewed for MDS assessments. The facility did not transmit R10's Entry MDS tracking assessment, admission Comprehensive MDS assessment and Annual Comprehensive assessment in a timely manner. Findings include: The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025, indicates: All Medicare and/or Medicaid-certified nursing homes must transmit required MDS records to the Centers for Medicare and Medicaid Services (CMS) . Required MDS records include: Admission, Quarterly, Annual, and Discharge assessments and Entry Tracking records . For Entry and Death in Facility tracking records, information must be transmitted within 14 days of the Event Date. Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. For the admission assessment, the Care Area Assessment (CAA) Completion Date must be no later more than 13 days after the Entry Date. For the Annual assessment, the CAA Completion Date must be no later than 14 days after the ARD. R10 admitted to the facility on [DATE]. R10's Entry Tracker MDS has an assessment reference date (ARD) of 5/30/25. R10's Entry Tracker MDS has an accepted transmitted date of 7/6/25. Of note, this is greater than 14 days.R10's admission Comprehensive MDS assessment has an ARD of 5/30/25. R10's admission Comprehensive MDS assessment has a transmitted date of 7/6/25. Of note, this is greater than 27 days. R10's Annual Comprehensive MDS assessment has an ARD of 5/19/26. R10's Annual Comprehensive MDS assessment has a transmitted date of 7/1/26. Of note, this is greater than 28 days. On 7/8/26 at 2:45 PM, Surveyor interviewed DON B (Director of Nursing). DON B indicated she is responsible for the transmission of the MDS assessments. DON B indicated the assessments were transmitted late.

Based on interview and record review, the facility did not ensure that the comprehensive care plan was reviewed by the interdisciplinary team and resident/resident representative after each assessment, including both the comprehensive and quarterly review assessments for 1 of 3 residents (R14), reviewed for care conference, out of 11 sampled residents.R14 did not have quarterly care conference meetings.Evidenced by:Surveyor requested facility policy for Care Conferences. NHA A (Nursing Home Administrator) stated there is no facility policy; regulation is followed in relation to care conferences.R14 admitted to the facility on [DATE].R14's most recent Care Plan Meeting note is dated 4/1/25.On 7/8/26 at 9:56 AM, Surveyor interviewed SW C (Social Worker) and asked about frequency of care conference meetings. SW C stated they are usually about every 3 months, but may be more often with significant change. Surveyor asked when R14's last care conference was held. SW C stated it looks like it has been a while. SW C confirmed that 4/1/25 was the last conference documented in R14's record.On 7/8/26 at 1:19 PM, Surveyor interviewed DON B (Director of Nursing) who confirmed that 4/1/26 was the last documented care conference. DON B stated we are not in compliance with our care conferences right now; I would expect them to be quarterly.On 7/8/26 at 1:34 PM, Surveyor interviewed NHA A who stated that quarterly care conferences are expected.

Based on observation, interview and record review, the facility did not ensure that residents with limited mobility receive appropriate services, equipment, and assistance to maintain or improve mobility for 2 of 4 residents (R1 and R17) reviewed for mobility. R1 did not have restorative PROM (passive range of motion) completed per order. R17 did not have restorative PROM completed per order. This is evidenced by: Example 1 R1 is a long term resident of the facility. R1 has the following Diagnoses: [REDACTED]. R1's restorative program for PROM consists of: flexion and extension at bilateral knees, ankles, elbows, wrists. Abduction/adduction bilateral shoulders and hip 10 reps (repetitions) to 15 reps up to two times a day every day. Goal- Prevent decline in ROM (range of motion) and prevent worsening of or development of additional contractures. R1's restorative documentation from computer system documents that from 7/1/19-9/25/19, R1 had PROM completed on the following dates: 7/1/19, 7/20/19, 8/10/19, 9/4/19, 9/8/19, 9/11/19, 9/12/19, 9/13/19, 9/17/19, and 9/21/19. R1 did not receive PROM per her order for 77 days from 7/1/19-9/25/19. R1's CNA Care Kardex documents, in part: .flexion and extension at bilateral knees, ankles, elbows, wrists. Abduction/adduction bilateral shoulders and hip 10 reps to 15 reps up to two times a day every day. Goal- Prevent decline in ROM and prevent worsening of or development of additional contractures . R1's care plan documents, in part: .I need my restorative aide to follow my restorative plan . R1's Restorative Nursing Note, dated 9/14/19, states, in part: .Resident continues to participate in and allow completion of PROM programs . On 9/24/19 at 1:43 PM, Surveyor interviewed CNA C (Certified Nursing Assistant). Surveyor asked CNA C how she knows who has restorative programs; CNA C stated the programs are on the residents care sheet and in an orange sleeve labeled restorative programs. Surveyor asked CNA C what restorative program R1 has; CNA C said R1 has a feeding program and PROM. Surveyor asked CNA C how many times a day the PROM program is, CNA C said up to BID (twice a day) as she tolerates. Surveyor asked CNA C how I would know if a residents' restorative program had been completed, CNA C replied it is documented in the computer. Surveyor asked CNA C if there is no documentation in computer for a restorative program, what does that mean; CNA C stated it was not done. Example 2 R17 is a long term resident of the facility. R17 has the following Diagnoses: [REDACTED]. R17's restorative program for PROM is- RLE (right lower extremity) and LLE (left lower extremity) 15 reps to 20 reps once a day every day. Goal- Prevent contracture and maintain circulation. R17's restorative documentation from computer system documents that from 7/1/19-9/25/19, R17 had PROM completed on the following dates: 7/1/19, 7/3/19, 7/8/19, 7/9/19, 7/10/19, 7/13/19, 7/23/19, 7/24/19, 8/1/19, 8/2/19, 8/7/19, 8/10/19, 8/11/19, 8/13/19, 8/19/19, 8/25/19, 9/13/19, and 9/24/19. R17 did not receive PROM per his order for 69 days from 7/1/19-9/25/19. R17's CNA Care Kardex documents, in part: .RLE and LLE 15 reps to 20 reps once a day every day. Goal- Prevent contracture and maintain circulation . R17's care plan documents, in part: .I need my restorative aide to follow my restorative plan for PROM and swallowing . R17's Restorative Nursing Note, dated 9/14/19, states, in part: .Resident continues to allow for/tolerate 8-10 min (minutes)/ (per) day of Passive RPM exercises. When discussed with RNA's (restorative nursing aides), they indicate she show no sx (symptoms) of pain and will freq. (frequently) state stretch me out more! . On 9/24/19 at 1:43 PM, Surveyor interviewed CNA C. Surveyor asked CNA C what restorative program R17 has; CNA C said PROM and eating program. Surveyor asked CNA C how many times a day the PROM program is, CNA C said QD (every day). On 9/25/19 at 9:13 AM, Surveyor interviewed RN MDSC D (Registered Nurse, Minimum Data Set Coordinator). Surveyor asked RN MDSC D how the restorative programs are initiated for residents, RN MDSC D said the majority are from therapy, initially, and then when we (RN MDSC D) and RA (restorative aide) review, we talk with therapy and see if therapy can screen if things aren't going well or continue with program as written if all is going well. Surveyor asked RN MDSC D if each resident should have restorative program completed as written, RN MDSC D said yes, they should be done per order. Surveyor asked RN MDSC D if there was anything else regarding restorative programs for R1 or R17 that Surveyor should know; RN MDSC D stated R17 often declines. Surveyor asked RN MDSC D if that should be documented, RN MDSC D said yes; we're working with our computer system company to rectify that. On 9/25/19 at 10:25 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B should staff complete restorative programs as written; DON B stated yes, they should be completed as written. Surveyor asked DON B what should be done if not completed; DON B said they are working with their computer system company on a resolution for this.

Based on interview and record review, the facility did not ensure reporting of communicable diseases or infections to NHSN (National Healthcare Safety Network) which has the potential to affect 25 out of 25 residents residing within the facility. Facility is not reporting CRE (Carbapenem-resistant [MEDICATION NAME]) (multi-drug resistant organism) values to NHSN monthly. This is evidenced by: Facility policy entitled Communicable Diseases Reporting Policy, reviewed on 9/19, states, in part: Purpose: To outline infection control & prevention (ICP) and nursing responsibilities in reporting communicable diseases.CRE .Nursing Home ICP is responsible for reporting CRE cases via NHSN and contacting WI DPH . On 9/24/19 at 1:08 PM, Surveyor observed DON B (Director of Nursing) and Receptionist [NAME] log on to NHSN. Receptionist [NAME] showed Surveyor the facility's reporting history for (MONTH) 2019 and (MONTH) 2019, which indicated that CRE is not being reported to NHSN. The facility was indicated as reporting C.Diff ([MEDICAL CONDITION]) only. On 9/24/19 at 1:52 PM, Surveyor placed a call to DPH Contact F (Department of Public Health) regarding CRE reporting and conferred rights. On 9/25/19 at 8:39 AM, DPH Contact F left a message for Surveyor indicating that the facility has conferred rights, but has not been reporting zero cases of CRE each month. DPH Contact F indicated she will be reaching out to the facility to ensure their Infection Control Preventionist is enrolled and reporting CRE every month. On 9/25/19 at 10:03 AM, Surveyor interviewed DON B regarding the facility's Infection Control program. DON B indicated that CRE had not been reported based on what she could see in NHSN and there are no cases of CRE in the building. DON B indicated CRE needs to be reported even if zero cases in the facility every month.

Based on record review and interview, in 4 of 17 residents reviewed (R26, R37, R29, and R30), the facility did not, at the time of transfer for hospitalization , provide to resident and a family member or legal representative written notice which specifies the duration of the Bedhold Policy. R26 was transferred from the facility. R26's family / legal representative was not provided written notice of the duration of the bedhold and the associated costs. R37 was transferred from the facility. R37's family / legal representative was not provided written notice of the duration of the bedhold and the associated costs. R29 was transferred from the facility. R29's family / legal representative was not provided written notice of the duration of the bedhold and the associated costs. R30 was transferred from the facility. R30's family / legal representative was not provided written notice of the duration of the bedhold and the associated costs. This is evidenced by the following: The facility policy titled, Bedhold Policy, undated, includes, in part: (Facility name) will hold a residents bed for 15 days with a signed bedhold form. The resident's bed will not be given up during 15 days unless written permission is obtained from the resident or legal representative. If the resident is out of (Facility name) longer than 15 days, Social Worker and or nursing will talk with resident and family to discuss discharge plans, or other options. (Facility name) will hold a bed while you are absent for temporary stays in a hospital or other healthcare facility. If you are absent overnight for any reason, including hospitalization , a bed will be held and billed at the daily rate. If you are transferred from (Facility name) and do not wish to have a bed held for you, (Facility name) shall have no obligation to readmit you. Example 1 R26's original admission was on 8/30/16 and recent admission to the facility was on 5/12/18. On 5/11/18, R26 was transferred from the facility to the hospital via ambulance. Review of the clinical record did not provide evidence of the facility's written notice of the bedhold for R26's transfer to the hospital that occurred on 5/11/18. There was no documentation that the written notice was provided to the resident or legal representative upon transfer to the hospital. On 7/2/18, at 1:22 PM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding the facility Bedhold Policy. NHA A indicated there was not a bedhold offered as we have beds open and were willing to take R26 back. NHA A indicated the bedhold should be offered. NHA A indicated there was a Progress Note indicating R26's bedhold was effective dated 5/11/18. Example 2 R37 was admitted on [DATE] with a readmission date of [DATE]. On 8/3/17, R37 was transferred from the facility to the hospital via ambulance. Review of the clinical record did not provide evidence of the facility's written notice of the bedhold for R37's transfer to the hospital that occurred on 8/3/17. There was no documentation that the written notice was provided to the resident or legal representative upon transfer to the hospital. 7/2/18 at 1:53 PM, Surveyor interviewed NHA A regarding R37's bedhold notice. NHA A could not provide written documentation that a bedhold was offered to R37. NHA A indicated that a Progress Note documents a Medicaid Bedhold was effective 8/3/17. The facility could not provide written documentation that a bedhold was offered, reviewed, and / or signed by the resident or representative. Example 3 R29's [DIAGNOSES REDACTED]. R29 is his own decision maker. R29's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/26/18 indicates R29 was discharged to the hospital and his return was anticipated. R29's MDS, with an ARD of 5/11/18, indicates R29 was discharged to the hospital and his return was anticipated. There is no documented evidence and the facility was unable to provide evidence that R29 was provided a bedhold for his hospital transfers on 4/26/18 or 5/11/18. Example 4 R30's [DIAGNOSES REDACTED]. R30 is not her own decision maker. R30's MDS with an ARD of 5/11/18 indicates R30 was discharged to the hospital and her return was anticipated. There is no documented evidence and the facility was unable to provide evidence that R30 or R30's representative was provided a bedhold for her hospital transfer on 5/16/18. On 7/3/18 at 1:31 PM, Surveyor interviewed NHA A. NHA A stated there was no evidence that any of the residents or their representatives received a bedhold. NHA A stated he would expect any resident who was transferred to the hospital would receive information on bedhold availability.

Based on observation, interview and record review, the facility did not ensure that a resident who enters the facility without a PI (Pressure Injury) does not develop a PI for 1 of 17 residents reviewed (R147). R147 was admitted to the facility without a PI and was identified to be at risk for PI development. Interventions were not put into place to prevent R147 from developing a PI to his posterior scrotum. R147 was observed sitting in his w/c (wheelchair) on pillows without a cushion and lying in bed with his scrotum resting on his Foley catheter port / tubing. (It is important to know that R147's Panacea mattress was rated for up to 350 pounds. R147's admission weight was 405.7 pounds, and R147 was not provided with a pressure relieving cushion for his w/c.) This is evidenced by: The facility's Policy entitled Skin Integrity Protocol, with a revision date of 7/17, includes, in part: Purpose: the skin integrity of a resident will be preserved through adequate nutrition and hydration, routine inspection of the skin, compliance with proper body alignment and positioning, and maintenance of maximum mobility. Interventions: Braden (PI risk assessment) Resident's that score 18 or less initiate skin integrity Nursing Orders. These may include special mattress, assess pressure points under medical devices. Choose appropriate support surface. Place foam or breathable dressing under medical devices. Pressure Injury Prevention Points, dated 4/16, Repositioning and Mobilization - 10. Use a pressure redistribution chair cushion for individuals sitting in chairs or w/c. R147's Admission MDS (Minimum Data Set), dated 6/25/18, BIMS (Brief Interview for Mental Status) scored 15, indicating R147 is cognitively intact. Section G0110 A. Bed Mobility and B. Transfer status: indicates R147 requires extensive assistance with 2 physical assist. Section M0150: Risk of PI indicates R147 is at risk for PI. Section M0210: unhealed PI indicates R147 does not have a PI. Section M1200 Skin and Ulcer Treatments: A. Pressure reducing device for chair and B. Pressure reducing device for bed were checked. R147's Braden Scales, dated 6/18/18 and 7/2/18, both scored a 17 which indicate R147 is at risk for skin break down. R147's CAA (Care Area Assessment), dated 6/25/18, includes, in part: CAA triggered due to needing extensive assistance with one or two staff members for bed mobility. Also, indicated because R147 is at risk for developing pressure related injuries. Related to DX (Diagnosis) DM (Diabetes), Heart failure, Hypertension, weakness, [MEDICAL CONDITION], adult failure to thrive, and depression. Last Braden on 6/18/18 had a score of 17. However, due to R147's size and presence of moisture to skin folds, R147 is at increased risk. (Note, all skin concerns are not pressure injuries but moisture related skin damage.) Prior to admittance to hospital, R147 was independent at own apartment. Poor self cares and nutrition per own report. Risk including development of pressure injuries, worsening of current skin conditions, pain, infection, further need for dependence, isolation and withdrawal. No referrals are indicated at this time, as skin well managed through attending physician. Will proceed to care plan to provide risk reduction. R147's Comprehensive Care Plan, I have sensitive skin with ulcerations that come and go, dated 6/27/18, includes, in part: because I am diabetic and can't move around very well on my own. I am morbidly obese. I need my nurses to reduce pressure and friction between myself and my bed or chair. I need my aides to reduce pressure and friction between myself and my bed or chair. Use pillows for supporting me. Goal: have my skin heal. Keep my skin healthy and intact. Physician Orders, dated 6/18/18, includes, in part: Apply [MEDICATION NAME] to posterior pannus (abnormal layer of fibrovascular tissue or granulation tissue) and scrotum as needed for skin breakdown / ulcers. On 6/27/18 at 1:38 PM, Surveyor observed R147's skin treatment with RN C (Registered Nurse). R147 was lying in bed on a Panacea mattress. Surveyor observed R147 lying on a soaker pad with his Foley catheter tubing /port positioned below his enlarged scrotum and pannus. RN C applied [MEDICATION NAME] cream (reduces the swelling, itching, and redness) to R147's bilateral legs. RN C applied [MEDICATION NAME] to R147's lower abdomen and applied [MEDICATION NAME] powder to the bilateral groin folds. Surveyor observed a pillow in R147's w/c. RN C assisted R147 in rolling over to observe the skin on R147's buttocks, pannus and scrotum. RN C indicated there was a small open area on the back of R147's scrotum that looks better. RN C placed a small 2 x2 inch size [MEDICATION NAME] dressing on the back of R147's scrotum. On 6/27/18 at 3:30 PM, Surveyor asked NHA A (Nursing Home Administrator) for the manufacture guidelines for R147's Panacea mattress. On 7/2/18 at 8:30 AM, Surveyor reviewed the facility purchase order, dated 6/27/18, for a Bariatric panacea original foam mattress 800 pound capacity, to be delivered by 7/2/18. Date needed - indicated ASAP (as soon as possible) documented on the form. On 7/2/18 at 1:43 PM, NHA A indicated to Surveyor the facility now realizes that R147's mattress is a Flip Foam mattress and is rated for a resident whose weight capacity is 350 pounds. NHA A indicated that a new mattress was ordered and delivered today. NHA A gave Surveyor a copy of the Panacea Bariatric Foam mattress recommendations that indicates it has an 800 pound weight capacity. Physician Orders, dated 7/2/18, includes, in part: Apply [MEDICATION NAME] to posterior pannus open area until healed and then daily for protection from catheter tubing / port. Check placement of [MEDICATION NAME] to the posterior pannus open area. AM and N[NAME] (Night) until healed. Then daily for protection. On 7/2/18 at 3:07 PM, Surveyor interviewed RN L regarding R147's skin and any open areas that she has noted. RN L indicated that she saw a pin point open area on R147's scrotum. Review of R147's skin documentation notes, dated 7/2/18 at 10:46 PM, includes, in part: posterior scrotum 0.5 cm (centimeter) diameter denuded pink area. Cleansed with soap and water. ¼ [MEDICATION NAME] applied. Open area to posterior mid pannus 0.5 cm x 0.5 cm x 0.1 cm. Nursing adjusts the catheter port alongside the pannus when in bed. R147 gets up in the w/c during the day hours. On 7/3/18 at 1:08 PM, Surveyor observed R147's wound treatment to his scrotum. R147 continues to have pillows in his w/c. Per RN C, the facility noted 2 open areas last night. One on R147's scrotum and the other one his pannus. RN C indicated the nursing staff is going to position the catheter tubing more to the side. Surveyor asked R147 how he liked the new mattress. R147 indicated it feels like the previous one. RN C indicated that getting pressure off R147's scrotum from the catheter has helped. Observation of R147's scrotum indicated a small open area that was circular in shape. RN C applied [MEDICATION NAME] to the open area on R147's scrotum. Surveyor asked RN C to describe the area on R147's scrotum. RN C indicated that it looks to be 1 cm circular shaped. (To be noted, the old dressing contained a small amount of red drainage.) Surveyor asked RN C what caused this open area on R147's posterior scrotum. RN C indicated the catheter position is right in line with the open area. Surveyor asked R147 if he has any pain in the open area on his scrotum. R147 indicated he does have pain. On 7/3/18 at 1:30, Surveyor interviewed OT F (Occupational Therapist) regarding R147's w/c and if a cushion would be appropriate for him. OT F indicated that she did a w/c cushion assessment on 6/26/18 which, includes, in part: R147 has 2 w/c's and no w/c cushion in chairs. Assessed and measure for proper w/c cushion as R147 currently is using 3 pillows for position and comfort. Informed DON B (Director of Nursing) of appropriate bariatric w/c cushion and will work with (Name of insurance company) to order and obtain this cushion. OT F indicated the insurance company has approved the cushion recommendation. On 7/3/18 at 2:30 PM, Surveyor interviewed DON B regarding R147's mattress upon admission. DON B indicated the facility thought R147 lost so much weight that he would not require a bariatric bed. DON B indicated that it was an oversite and the Panacea Flip Foam mattress did not fit his poundage. DON B indicated that no one gave it a thought. Surveyor asked DON B if that was an appropriate mattress for R147. DON B indicated no. Surveyor asked DON B if R147 should have been assessed for a w/c cushion. DON B indicated therapy did screen R147 for a w/c cushion and the facility was waiting for (Insurance Company name) to approve. DON B indicated R147 should have had everything needed upon admission. Surveyor asked DON B if R147 should have been assessed sooner for a w/c cushion. DON B indicated yes, R147 should have been assessed right away. Surveyor asked DON B what caused the PI on R147's scrotum. DON B indicated that she was not aware of an open area. Surveyor reviewed her observation with RN C. Surveyor asked DON B what SOP (Standards of Practice) the facility follows for wounds, PI, skin alterations. DON B indicated that the facility follows the NPUAP (National Pressure Ulcer Advisory Panel) guidelines and AMDA (American Medical Directors Association). Surveyor asked DON B who is WCC (Would Care Certified) at the facility. DON B indicated RN H is WCC. The facility did not prevent a pressure related device injury when having the knowledge of R147's weight, diagnosis, and the facility did not fit R147 with an appropriate mattress for his weight, nor obtain a pressure relieving device for either w/c.

Based on record review and staff interviews, the facility did not ensure 2 of 3 residents (R35 and R41) were issued the written liability notice when Medicare covered services were terminated for coverage reasons by the facility and the residents remained at the facility. R35's Medicare covered services were terminated by the facility on 4/12/18, and R35 was not issued a written Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) or one of the uniform denial letters regarding potential liability and a written notice of R35's right to request a standard appeal. R41's Medicare covered services were terminated by the facility on 6/4/18, and R41 was not issued a written SNFABN or one of the uniform denial letters regarding potential liability and a written notice of R41's right to request a standard appeal. Evidenced by: The Centers for Medicare and Medicaid Services (CMS) Ref: Survey and Certification Group (S&C)-90-20 Memo, dated 1/9/09, directs facilities to inform beneficiaries on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable and necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for non-covered services. The potential liability is at a minimum the daily rate per day. To meet this requirement facility's must use either the SNFABN (form CMS ) or one of the five uniform denial letters found on the CMS web page. The CMS cannot replace the SNFABN form. On 7/2/18 at 9:18 AM, Surveyor interviewed SW D (Social Worker - Social Services Representative) regarding the Beneficiary notices given to R35 and R41. SW D indicated that she has 8 weeks of schooling left and will then be the in the role of the social worker. Surveyor asked SW D to see the documentation for R35 and R41 Notice of Medicare Non-Coverage that was issued when services were ending. SW D indicated that she thought the SNF/ABN form covered the notice. SW D indicated that she thought option 2 on the SNFABN (CMS- form) would cover the notice to be given. On 7/2/18 at 9:00 AM, Surveyor reviewed a sample of residents' Medicare Notices provided when Medicare services were terminated for coverage reasons. R35's Medicare services were terminated by the facility on 4/12/18. R35 was not provided with the Notice of Non-Coverage (CMS- ). R35 was appropriately provided with a written SNFABN (CMS- form). R35 remained in the facility. On 7/2/18 at 9:10 AM, Surveyor reviewed a sample of residents' Medicare Notices provided when Medicare services were terminated for coverage reasons. R41's Medicare services were terminated by the facility on 6/4/18. R41 was not provided with the Notice of Non-Coverage (CMS- ). R41 was appropriately provided with a written SNFABN (CMS- form). R41 remained in the facility.

Based on interview and record review, the facility did not ensure residents drug regimens are free from unnecessary [MEDICAL CONDITION] drugs for 1 out of 6 residents (R9) reviewed for unnecessary medications out of a total of residents sampled. R9's Physician order [REDACTED]. Evidenced by: The facility's policy Psychoactive Medication Assessment/Consent Guidelines, dated 5/17, includes, in part, the following: 7. Per CMS (Centers for Medicare and Medicaid Services) rules: For antipsychotic, a 14 day limitation is applied to all PRN (as needed) orders: as a result these orders may not extend beyond the 14 day limit. To continue to use their use, a new order for the PRN antipsychotic may be written if the prescribing practitioner directly [MEDICATION NAME] and assesses the resident and documents clinical rationale. Rationale must include the benefit of the medication for the resident. This documentation is required every 14 days for resident receiving a PRN antipsychotic without exception, even Hospice patients. R9's Telephone Order, dated 6/12/18, includes, in part, the following: [MEDICATION NAME] 0.5 mg (milligrams) tablet (1) PO (oral) as needed every 6 hours for anxiety. (It is important to know this [MEDICATION NAME] order was not renewed on 6/16/18.) R9's Medication Administration Record [REDACTED]. On 7/3/18 at 2:11 PM, Surveyor interviewed RN H (Registered Nurse). RN H stated everyone is responsible for monitoring PRN [MEDICAL CONDITION] medications. RN H stated R9's physician should have been notified when R9's [MEDICATION NAME] order was nearing 14 days and a decision should have been made to either discontinue the medication or extend the medication with a face-to-face visit with the physician. RN H stated we did make the physician aware and he discontinued the [MEDICATION NAME] and is coming in tomorrow to do rounds with R9.

Based on interview and record review, the facility did not ensure each resident (R) received nutritional and hydration care and services consistent with the residents comprehensive assessment, to ensure residents at risk or nutritionally impaired are recognized, evaluated and needs addressed for 1 of 17 sampled residents (R49). R49's Dehydration Assessment showed she was at risk for dehydration as she had signs and symptoms of poor skin turgor (how quickly your skin returns to its normal position after being pinched), dry mucous membranes, and cracked lips. R49's fluid intake was not monitored, dehydration was not further assessed, care planned or reported to RD I (Registered Dietician). Findings as follows: Example 1 R49's [DIAGNOSES REDACTED]. R49 is her own decision maker. R49's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/23/18 indicates R49 is cognitively intact and acts independently after set up. R49's Care Plan, I Need to be offered extra fluids, dated 3/6/18, includes the following approaches: I need my nurse to give me fluids consistently throughout the day, observe me for changes in my mental status or behavior, monitor my weight regularly, offer me a variety of fluids, weigh me as ordered, keep my fluids within reach. R49's Care Plan, I need to have small and frequent meals that offer adequate protein and are low in sodium, dated 3/8/18, includes the following approaches: I need my nurse to provide my nutrition and fluids as scheduled. I need my aides to record how much I drink and eat. I need Dietary Staff to provide me with protein rich vegetarian options, because I am a vegetarian. I need everyone to follow my diet plan. R49's Dehydration Assessment, dated 3/6/18, includes, in part, the following: Dehydration Assessment: Admission. Contributing factors: needs assist with intake. Signs and symptoms: poor skin turgor, decreased intake. Interventions: Fluids offered water nutritional supplements, ice chips. Provide 30 ml/kg (milliliter per kilogram) of fluids, weight as ordered, care planned, monitor labs monitor vital signs, frequent small meals. Outcome: at risk for dehydration. R49's Dehydration Assessment, dated 3/16/18, includes, in part, Dehydration Assessment: Admission. Contributing factors: difficulty obtaining fluid, [MEDICAL CONDITION]. Signs and symptoms: Functional impairments which make it difficult to obtain fluids, end of life care. Interventions: fluids offered . Nutritional supplements, vitamins, antidepressant as ordered, weight as ordered, monitor labs, monitor vital signs. Outcome: at risk for dehydration. R49's Dehydration Assessment, dated 4/16/18, includes, in part, the following: End stage [MEDICAL CONDITION], needs assist with intake, consistently eats less than 25% of meals, supplements with strawberry Ensure. Signs and Symptoms: Poor skin turgor, dry mucous membranes, cracked lips, resident and family considering palliative care/Hospice. Interventions: Fluids offered to resident likely, ice cream/custard as she requests, antidepressants as ordered, ice chips, weight as ordered, monitor vital signs, frequent small meals and snacks offered and available. Outcome: at risk for dehydration. R49's Physician Communication Fax Data Sheet, dated 4/16/18, included, in part, the following: Nurse communication: Attending Physician (Physician's Name). Resident has had a noted weight loss of 22.8 lbs (pounds) in last 35 days. There has been no significant change in her eating habits, however, she is presenting as dehydrated with an increase in fatigue. Resident is Type 2 diabetic and last HgA1C (Hemoglobin) not noted in electronic chart. Consider order for HgA1C and fasting glucose: Please respond with recommendations. Thank you. Signed by RN E (Registered Nurse). MD (Medical Doctor) Communication/Orders: Ok to order FBS (fasting blood sugar) and A1C. Signed 4/16/18. On 7/3/18 at 2:51 PM, Surveyor interviewed RD I. RD I stated she did not know about R49's hydration issues. RD I stated she would expect staff to inform her if any resident has hydration issues so she could assess them and make recommendations. RD I stated R49's hydration concerns should have been further addressed on the care plan and her fluid intakes should have been monitored. On 7/3/18 at 3:09 PM, Surveyor interviewed RN H; RN H is the Assistant Director of Nursing. RN H stated RD I should have been informed of R49's dehydration status.

Based on interview and record review, the facility did not ensure a Comprehensive Care Plan was revised after care plan development for 2 of 17 sampled residents (R21 and R38). R21 triggered for pain on her most recent MDS (Minimum Data Set). The facility did not develop a care plan to address R21's pain. R38 takes [MEDICATION NAME]. R38's care plan did not address R38 taking [MEDICATION NAME] or being at risk of bleeding. This is evidenced by: Example 1 R21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R21's Quarterly MDS, dated [DATE], shows R21 has a BIMS (Brief Interview of Mental Status) of a 7 out of 15, which indicates moderate cognitive impairment. MDS indicates R21 is able to understand others and makes herself understood. Section J indicates R21 is not on a scheduled pain medication regimen, did not receive as needed (prn) pain medication, and did not receive non-medication interventions for pain. Section J also indicates R21 has pain almost constantly and this pain has limited her day-to-day activities in the last 5 days. R21 indicated her pain as being a 6 on a scale of 0 - 10. On 5/7/18, R21's pain assessment indicates the follow: R21 has pain, almost constantly, which has limited her activity in the past 5 days. R21 rated her pain at a 6 verbally, location of pain is her back. Onset/duration of pain: acute on chronic exacerbation, Usually after I am done making my bed, I have to sit down and rest. Description of pain: throbbing hot pain. Alleviating factors: rest, exacerbation factors: adult daily living activities. Current medications: [REDACTED]. Will care plan to anticipate pain needs. (Please note, no care plan was developed for pain until 7/3/18, after Surveyor asked for R21's care plan addressing her pain.) Non- medication interventions: R21 will reposition, rest in recliner, or stop activity and revisit when feeling better. On 7/3/18, RN E (Registered Nurse - Minimum Data Set) came to Surveyor with a copy of R21's care plan and last pain assessment. Surveyor's copy of R21's care plan for pain is dated 7/3/18. R21's pain assessment provided to Surveyor on 7/3/18 has hand writing by RN J, which states, in part, Pain was not care planned because the only time she complained was when (RN E) interviewed her. Takes [MEDICATION NAME] daily with no complaints of pain. R21's care plan, dated 7/3/18, indicates the following: I need to be comfortable, because sometimes I hurt and get tired out, I have Parkinson. I need my nurses to ask me if I hurt, offer me pain medication, walk around with me. I need my aides to be extra gentle with me, ask me if I hurt, tell the nurse if I hurt, keep my chair comfortable, make my bed comfortable, give me extra pillows if I want them and give me a massage. Goal to be comfortable. (Please note, R21's care plan does not indicate what comfortable means for R21. Her care plan does not address the type of pain R21 has or the location.) On 7/3/18 at 8:37 AM, RN E indicated to Surveyor that R21's care plan should have addressed pain. Example 2 R38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/2/18 at 10:54 AM, Surveyor conducted a record review on R38. R38's medical record indicates he takes [MEDICATION NAME] (blood thinner/anticoagulant) 2 mg by mouth on Tuesdays and Wednesdays and 4 mg by mouth on Sunday, Monday, Thursday, Friday and Saturday. R38 was noted to currently not have a plan of care in place for being at risk for bleeding, due to the use of blood thinners. Surveyor requested a copy of R38's care plan for his [MEDICATION NAME] use at this time. On 7/3/18 at 8:37 AM, RN E provided Surveyor with a copy of R38's care plan. R38's care plan indicates the following: 7/2/18 at 3:36 PM, I have the potential to fall and injure myself, because I am paralyzed. In the past, having low blood pressure and getting dizzy or light-headed. I need my nurses to monitor my positioning and transfers. Check for any signs of bleeding for falls or injury due to [MEDICATION NAME] use. I need my aides to frequently check on me, report any of my behaviors that might cause me harm to my nurse. Safely transfer me with Hoyer and 2 assist. My goal is to avoid injury. On Surveyors copy of 38's care plan, RN J hand wrote missed [MEDICATION NAME] goal when switched over to new care plan format. Present on old care plan format. RN E indicated that R38's care plan addressing [MEDICATION NAME] and risk of bleeding should have been revised and carried over to the new format.

Based on record review and staff interview, the facility did not ensure that each resident's MDS (Minimum Data Set) assessment was coded accurately. This was observed with 2 of 17 resident records reviewed (R148 and R16). R148's MDS was not marked for Hospice when she was admitted on Hospice Services. R16's MDS indicates she has a physical restraint, when R16 does not have a physical restraint. Findings as follows: Example 1 R148's Admission MDS, completed 6/18/18, indicates in Section 0 Special Treatments, Procedures, and Programs Hospice Care was not checked. Review of R148's Physician Orders, dated 6/11/18, includes, in part: admit to (Facility name) - Hospice. On 7/3/18 at 8:38 AM, Surveyor interviewed RN E (Registered Nurse - Minimum Data Set) who is responsible for the completion of the MDS. Surveyor asked RN E if R148 was on Hospice Services. RN E indicated that R148 was admitted from Assisted Living and was on Hospice and it was not included on the MDS. RN E indicated that the MDS was incorrectly marked. I will correct this right away. Example 2 R16's Significant Change MDS, dated [DATE], indicates that she has a physical restraint (anything adjacent to the body that the individual cannot remove easily, which restricts freedom of movement or restricts access to one's body) which is marked as other, and is indicated to be used daily. R16's CAA (Care Area Assessment), dated 4/27/18, states, in part: CAA triggered due to use of low bed and floor mat for resident safety. Resident does continue to have the ability to get up and out of bed if she so wishes. Resident is unable to ambulate independently and has a recent history of falling out of bed when reaching for object that was on bedside table. Mobility and balance further compromised by dementia and major [MEDICAL CONDITION]. Will review use of low bed and floor mat with multi-team and will refer to care plan for additional interventions. On 6/27/18 at 8:41 AM, Surveyor observed Certified Nursing Assistants (CNA) provide care for R16. Surveyor observed R16 to be free of restraints. During this time, Surveyor interviewed CNA K regarding R16's restraint. CNA K is unaware of R16 having a restraint and indicated R16 prefers to be in bed instead of getting up in her chair. On 7/3/18 at 8:37 AM, Surveyor interviewed RN E (Registered Nurse - Minimum Data Set) regarding R16's MDS being coded as having a restraint. RN E indicated she considered a low bed a restraint, but realized it was not restricting her movement from her baseline. RN E indicated this was coded incorrectly.

Based on interview and record review, the facility did not ensure each resident (R) or their representative had the right to participate in the care planning process for 1 of 17 sampled residents (R16). R16's activated Power of Attorney (POA) has not had the right to participate in establishing goals and outcomes of care due to the facility has not held a Care Conference for R16 since 9/21/2017. This is evidenced by: R16 was originally admitted to the facility on [DATE], with readmission on 8/30/16, with [DIAGNOSES REDACTED]. On 2/23/17, R16's HCPOA (Health Care Power of Attorney) was activated. R16's Care Conference note, dated 9/26/2017, states, in part: Care Conference: Quarterly Review: (POA's name) was present. R16 was laying down resting and (POA) preferred not to wake her for the meeting. She attends activities that may be of interest to her including musical entertainers, volunteer visits and manicures. R16 loves to read and is typically excited to share about the book she is currently reading. R16 is doing well and (POA) is pleased that she still finds pleasure in her days. He does not want to have her moved to another facility and is very pleased with the care she receives. Attended Care Conference: Family (POA), Staff (SW D (Social Worker - Social Services Representative), life enrichment, Registered Dietitian and a Registered Nurse (RN)). Date of Care Conference: 9/21/2017. Plan of Care (P[NAME]): P[NAME] correlates with Advanced Directives: DNR (do not resuscitate) and no extraordinary measures during end of life, comfort measures. (Please note, no further Care Conferences are indicated as being held since 9/21/17, which indicates R16 and her POA were not afforded the opportunity to participate in their care planning process and to be included in decisions and changes in care, treatment, and/or interventions.) On 7/2/18 and 7/3/18, Surveyor conducted a record review on R16 and noted there was no recent Care Conference, although, R16 has had two Significant Change MDS (Minimum Data Set) completed. (Significant Change MDS is required due to an increase/decline in status that impacts more than one area of their health status or requires review/revision of care plan. R16 has had a decline.) R16's Significant Change MDS' were completed on 3/14/18 and 4/24/18. R16's record indicated she had a Quarterly MDS completed on 11/1/17 and 1/30/18, without Care Conferences associated with these assessments. Social Service notes are as follows: 1/30/18 Visits: Writer visited resident. Purpose of note: Quarterly review. Social Service related problem(s): remain appropriate/current. Additional comments: Met with R16 who was finishing up with her breakfast. R16 enjoys being alone in her room and is content with privacy. R16 answers this Writer's questions without much elaboration. She identifies (family) as support to her, but she comments they are busy and only come when they can. R16 continues to refuse medications and needs redirection. 7/3/18 Purpose of note: Called and talked with (son/POA) to set up a Care Conference. He stated that he understood we had to do them, but he didn't feel it was really necessary as he has been in touch with nursing staff and understands what's going on. This Writer offered a phone conference if that would work better for (son) and he agreed that it would. Care Conference scheduled for 7/5/18 at 10 AM. Sent calendar invite to Care Conference Team. On 7/3/18 at 1:37 PM, Surveyor interviewed SW D regarding Care Conference for R16. SW D indicated that Care Conferences work by letting the resident know if they're their own person or if not, call the family to let them know it's coming up time for a Care Conference, see what's available for dates and times, then set up a conference. SW D indicates she would send out calendar invites to staff dietary, nursing, therapy etc., to join. SW D indicated Care Conferences are supposed to be quarterly. SW D stated yes indicating a Care Conference should be held regarding a significant change. SW D stated correct indicating R16 has not had a Care Conference in the last 9 months (9/2017). SW D indicated it's the SW's duty to keep track and ensure Care Conferences are held. SW D indicated working with MDS Nurse to figure out a plan on how to do conferences. SW D indicated if a signed copy is not in the chart, there is no documentation to show R16's POA was provided an updated copy since last Care Conference. SW D indicated she expects an updated care plan be provided to POA's.

Based on observation, interview and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents for 1 of 14 residents reviewed with falls out of a total sample of 17 (R33). R33 was observed in his electric wheelchair with a seatbelt on. The facility had not assessed R33's wheelchair or seatbelt, nor was the electric wheelchair or seatbelt on R33's care plan. Evidenced by: R33's [DIAGNOSES REDACTED]. R33 is his own decision maker. R33's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6/6/18 indicates R33 needs extensive assistance of 2 people for transfers, does not ambulate and has had falls since admission to the facility. R33's Fall Risk Assessment, dated 6/5/18, indicates R33 is at moderate risk for falls. R33's medical record indicated R33 slid from his wheelchair on 4/17/18, his power scooter tipped over on 2/9/18, he fell from his wheelchair 1/22/18 and he tipped out of his wheelchair on 12/27/17. On 6/26/18 at 3:26 PM, Surveyor observed R33 sitting in his electric wheelchair in the hallway of his unit. R33 had a seatbelt on. On 7/2/18 at 8:44 AM, Surveyor observed R33 sitting in his electric wheelchair in his room. R33 had a seatbelt on. On 7/2/18 at 2:58 PM, Surveyor interviewed CNA G (Certified Nursing Assistant). Surveyor asked CNA G how often R33 used the seatbelt in his electric wheelchair. CNA G stated R22 wore the seatbelt in his electric wheelchair every time he was in his electric wheelchair. (It is important to know R33 received a new electric wheelchair on or about 6/15/18. The electric wheelchair has a seatbelt attached to it. There is no evidence in R33's medical record that either the electric wheelchair or the seatbelt was assessed.) On 7/3/18 at 8:28 AM, Surveyor interviewed DON B (Director of Nursing). DON B stated R33's electric wheelchair and seatbelt were not assessed. DON B stated an assessment for the electric wheelchair and seatbelt should have been assessed when R33 first received them. DON B stated the electric wheelchair and seatbelt should also be on R33's care plan.

Based on interview and record review, facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 11 residents (R11) reviewed resulting in R11 being hospitalized and treated for [REDACTED]. The facility was aware R11 did not have a bowel movement (BM) during his hospital stay prior to admittance. During his stay at the Facility, he experienced Right upper quadrant and abdominal pain. R11 was sent to the hospital on 3/14 due to a change in condition related to not having a BM since prior to being admitted from the hospital; resulting in R11 having to undergo surgery for [REDACTED]. This is evidenced by: Facility policy entitled .Resident Care Policy, dated 09/2016, states in part: .Nursing care: .9. Residents care standards specific to LTC (long term care) .J. Bowel Care Regime: First day without BM (bowel movement) - prune juice or prunes, use prunes or power pudding prior to medication interventions, MOM (Milk of Magnesia) 30cc (cubic centimeters) regular strength PO (by mouth) PRN ( as needed) daily for constipation. Third day without BM - [MEDICATION NAME] suppository or fleets enema .Dietary consultation if difficulty with constipation . Facility policy entitled Resident Change of Condition Protocol, dated 03/2017, states in part: .II. System specific criteria .E. Musculoskeletal .2. New on-set of change in pain (intensity, duration, location) .F. [MEDICAL CONDITION] .2. Flank pain .G. Gastrointestinal 1. New on-set or change in intensity/characteristics of abdominal pain (severe tenderness, guarding, rebound, rigidity, decreased/absent bowel sounds) .3. New on-set or change in persistent nausea/vomiting. 4. Change in bowel pattern . R11 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. R11's History and Physical, dated 03/05/2017, states in part: .no constipation or diarrhea .positive bowel sounds, soft, nontender, nondistended . R11's Minimum Data Set (MDS) assessment, dated 03/14/2017, indicated that R11 requires 2 person extensive physical assist with bed mobility and transfers. Ambulation did not occur or only occurred 1 to 2 times within the look back period. Indicated R11 needed one person limited physical assistance to use the bathroom and indicated R11 was always continent of bowel. There is no data entered for Brief Interview of Mental Status (BIMS). R11's care plan, dated 03/15/2017, states in part: Problem: Constipation .Approach Nurses --- bowel regimen: offer PRN laxatives MOM, [MEDICATION NAME] sup. Offer Enema. Abdominal assessment. Give bowel prep per PO, provide privacy, Encourage fluids administer PRN laxatives as ordered. Encourage physical activity as tolerated. Update MD as needed. R11's care plan was not initiated until after he had been sent to theER on [DATE]. R11's 03/10/2017 Physician orders [REDACTED]. [MEDICATION NAME] Sodium 100mg tablet by mouth twice a day for constipation Fleet enema 7GM/118ML - 19GM/118ML enema 1 daily as needed for constipation Milk of Magnesia (MOM) 400mg/ml suspension 30ml regular strength by mouth daily PRN for constipation. [MEDICATION NAME] 10mg suppository one if no BM x 3 days, for constipation rectal [MEDICATION NAME] HCL 10mg tablet by mouth one every 8 hours PRN muscle spasm [MEDICATION NAME]-[MEDICATION NAME] 5mg-325mg 2 tablets by mouth two every 6 hours PRN for moderate to moderately severe pain (Discontinued 03/11/2017), [MEDICATION NAME] 5mg-325mg tablet by mouth two every 4 hours PRN for moderate to moderately severe pain (started on 03/11/2017), [MEDICATION NAME] 325mg 1 tablet by mouth every 4 hours as needed pain/fever [MEDICATION NAME] 325mg 2 tablets by mouth every 4 hours as needed pain/fever. [MEDICATION NAME] 250mg 1 tablet twice a day for 5 day pneumonia (antibiotic). [MEDICATION NAME] 40mg tablet by mouth daily, [MEDICATION NAME] 25MG I tablet by mouth daily Calcium - Vitamin D 500MG-200 unit table by mouth daily Please note the following medications have the ability to cause constipation: [MEDICATION NAME]-[MEDICATION NAME], and Calcium-Vitamin D. Also note there is no documentation showing staff tried to use Tylenol, to alleviate R11's pain, prior to using his [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]). 03/10/2017 at 10:44 AM, Pre-admission note states in part: . He has not had a BM in the hospital. Last known BM was 3/5/17 . 03/10/2017 between 1:56 PM and 10:58 PM, the facility staff contacted the physician multiple times regarding admission, order clarifications, Occupational and physical therapy order. There is no documentation that physician was updated on R11 not having a BM while in hospital. 3/10/17 PM shift through 3/13/2017 PM shift, R11's BM are documented as No BM. 03/10/2017 at 2:07 PM, note Musc/skeletal pain: states he has abdominal pain due to chronic cough, refused pain medication at this time. 03/10/2017 at 2:13 PM, Verbal Pain Assessment indicates R11 has frequently had pain or hurting in the past 5 days and has limited his day to day activity due to the pain. R11 indicated the pain was mild-moderate located in abdomen from cough, alleviating factors are rest, exacerbating factors cough and movement. Plan: encourage resident to use pillow to support abdomen when coughing. 03/10/2017 at 2:28 PM, Digestive findings: (within normal limits) no complaints per resident had abdominal pain related to cough, encourage pillow to support abdomen when cough. Abdomen: soft nontender Bowel Sounds: bowel sounds present. 03/10/2017 at 2:49 PM, Bowel: has complete control of bowel. Bowel problems: states I go when I go, does have bowel medication order. 03/10/2017 at 3:17 PM, Digestive findings: WNL no complaints at rest in bed. Questioned resident if he had pain with coughing and denies to this writer. Abdominal pain: (no pain) Abdomen: nontender soft. Bowel sounds: bowel sounds present all quadrants active. Vomitus: none. 03/10/2017 at 3:57 PM, nurses note: Refused- [MEDICATION NAME] Sodium 100mg tablet Reason: resident declined I don't need that. No documentation noted indicating nurse educated R11 on not taking the [MEDICATION NAME], which is a stool softener, when R11 has not had a BM since 03/05/17 per nursing notes and BM monitoring. 03/10/2017 at 9:16 PM, R11 received [MEDICATION NAME]-[MEDICATION NAME] 5MG-325MG tablet for comfort/lower Left side pain with cough. Teaching on splinting. On 03/11/2017 at 3:30 AM, [MEDICATION NAME]-[MEDICATION NAME] 5MG-325MG tablet given per request of pain to Right Left side rated at 8/10. On 03/11/2017 at 4:09 AM, nurses note indicates R11 is reluctant to cough & deep breathe due to abdominal pain. On 03/11/2017 at 4:14 AM, nurses note states in part: .Digestive findings: WNL no complaints Abdominal pain: (no pain). Abdomen: nontender soft Bowel sounds: bowel sounds present all quadrants. At 4:15 AM note states in part: .at time of assessment resident had complaints of pain to ride (SIC) side of abdomen r/t cough pain rated at 8/10 accepted prn pain medication with good results. On 03/11/2017 at 8:20 AM, Verbal Pain Assessment indicates R11 has occasionally had pain in the last 5 days to Right upper quadrant, alleviating factors are rest and [MEDICATION NAME], exacerbating factors position changes. Plan: prn [MEDICATION NAME] given. On 03/11/2017 8:20 AM, [MEDICATION NAME]- [MEDICATION NAME] 5MG - 325MG tablet given for Right side pain and at 8:21 AM, PRN Milk of Magnesia 400mg/5ml suspension given for constipation. Please note Facility policy, for BM regimen, indicates the First day without BM (bowel movement) to give prune juice or prunes, use prunes or power pudding prior to medication interventions. No documentation noted to indicate staff offered R11 prunes, prune juice or power pudding prior to using pharmacological interventions on 03/10/2017 or 3/11/2017. On 03/11/2017, at 10:11AM, physician notification note indicates: Resident is complaining of Right lower rib, Right upper quadrant pain, noted more with coughing and deep breathing, when seen by writer and physical therapist, feel it is muscular in nature. Asking about trying a K, T-pad for comfort, resident continues with [MEDICATION NAME] pain medication. Vital signs within normal limits, lungs noises thru out, being treated for [REDACTED]. R11 still has not had a BM since 3/5/17, there is no documentation showing staff updated the physician regarding R11 not having a BM. Staff had the opportunity to notify the physician, at this time, related to not having a bowel movement along with his abdominal pain. 03/11/2017 at 10:57AM, nurses note states in part: .it hurts on that Right side when I cough rating pain 5-7 pointing to Right lower rib and RUQ (Right upper quadrant) discomfort .and hurts when palpating. Please note this is the first time documentation shows R11 hurts when RUQ (RUQ is where part of your small bowel is located), is palpated, there is no update to the physician regarding this. On 03/11/2017 at 12:24 PM, physician notification note indicates: spoke with (physician name) regarding: vitals, lung assessment, pain assessment on resident-pain when coughing, current pain medications, and current [MEDICATION NAME] being given. Result: New orders received and noted 03/11/2017 1) K-pad or T-pad may use every shift as needed for muscle discomfort on Right side (may alternate with cold). 2) Cold packs every shift as needed for muscle discomfort on Right side. 3) utilize prn (as needed) for pain. 4) [MEDICATION NAME] 5/325 change to two tablets by mouth every 4 hours as needed for pain. 5) Update (physician name) on Monday if pain to Right side is not relieved. (Please note Monday is 3/13/2017) On 3/11/2017 at 2:27 PM, nurses note: spoke with resident about using Cyclobenezaprine (SIC) for muscle spasms, resident did not want to use right now, but state, I may try it tonight. On 03/11/2017 at 3:25 PM, nursing note states in part: .Digestive findings: WNL no complaints. Abdominal pain: (no pain) none right now. I'm pretty good. Abdomen: nontender soft. Bowel sounds: bowel sounds present all quadrants. Vomitus: none. On 03/11/2017 at 6:26 PM, [MEDICATION NAME]-[MEDICATION NAME] 5MG-325MG 2 tablets given for pain in abdomen with cough. 03/12/2017 at 12:08 AM, nurses note states in part: .PRN med result: 00:08 (12:08 AM) symptoms reduced. On 03/12/2017 at 12:45 AM, [MEDICATION NAME] - [MEDICATION NAME] 5MG-325MG 2 tablets given for continues abdominal pain rated 5/10 with coughing, resident encouraged to splint with pillow. On 03/12/2017 at 5:58 AM, nurses note states in part: .Resident reluctant to C&DB due to abdominal pain with cough . On 03/12/2017 at 6:14 AM, nurses note states in part: .BM Output: Resident accepted MOM on AM shift 3-11-17 with no results as of yet. Digestive findings: WNL no complaints. Abdominal pain: (no pain). Abdomen: nontender soft. Bowel sounds: bowel sounds present all quadrants. On 03/12/2017 at 6:15 AM, Nurses note states in part: .Musc/skeletal pain: at time of assessment resident requested prn pain medication for abdominal pain r/t coughing with good results, On 03/12/2017 at 8:31AM, Milk of Magnesia 400mg/5ml suspension given for constipation. Follow up after 30 minutes. 03/12/2017 09:01. 03/12/2017 at 10:34 AM, nurses note states in part: .Musc/skeletal pain: per resident the coughing is less and the pain is better today . Digestive findings: WNL no complaints. Abdomen: soft nontender. Bowel sounds: bowel sounds present all quadrants resident given MOM for constipation. On 03/12/2017 at 3:27 PM, nurses note states in part: .Cough: occasional-using the splinting and K pad to ribs/abdomen for pain . On 03/12/2017 at 3:32 PM, nurses note states in part: B.M. Output: denies any pain or discomfort r/t constipation. Abdomen is soft and nontender. Passing gas. Appetite 100% of meals. Offered suppository or enema. No I want to let the MOM and the scheduled softeners work . Digestive findings: WNL no complaints. Abdominal pain: (no pain) much better today when I cough. Not as much pain. Denies any need for intervention. Using the K pad and splinting with coughing. Abdomen: nontender soft. Bowel sounds: bowel sounds present all quadrants. On 03/13/2017 at 1:14 AM, R11's nurses note states in part: .resident splinting to cough and utilizing Kpad for warmth/heat to soothe sore muscles to abdomen . (no pain rating documented to indicate what pain level sore is indicated to be) On 03/13/2017 at 1:16 AM, nurses note states in part: .B.M. Output: Resident has not had BM yet, has been taking MOM and gets stool softener.I am not worried about having a BM, it will happen when it is time. Digestive findings: WNL no complaints. Abdominal Pain: (no pain). Abdomen: nontender soft. Bowel sounds: bowel sounds present all quadrants. 03/13/2017 at 1:17 AM, nurses note states in part: .Musc/skeletal pain: Resident states pain is at a 4 or 5/10 which is an acceptable level for him. Declined pain medication I do not need it now, the heating pad is helping. Physician was not updated at this time regarding R11 continuing to have Right side pain, which has not been relieved; as noted above as sore. In addition, physician was not updated on R11, not having a BM while taking narcotic pain medications, of which R11's narcotics were increased from one tablet to two tablets. Narcotics cause constipation. R11 also takes [MEDICATION NAME], which causes an individual to excrete excess fluid, which can result in constipation as well. On 03/13/2017 at 7:28 PM, nurses note states in part: milk of magnesia 400mg/5ml suspension given for constipation. On 03/13/2017 at 11:29PM, nurses note states in part: med ineffective Action: continue to observe. This is day 8 for R11 going without a BM after being admitted to the facility, with a total of 5 days without at the hospital prior to admit and now 3 days since admission to Facility per nursing notes and BM monitoring. No documentation indicating that a physician was notified of R11 not having a BM and staff are aware MOM was ineffective. In addition, there is no documentation indicating staff provided non-pharmacological interventions such as prune juice, prunes, or power pudding to R11 during the past 3 days. There is no indication that staff followed bowel regimen per the Facility policy. R11 has had 3 doses of MOM and has not yet received an enema or suppository, although he has orders for it. 3/14/2017 NOC stool output documented: Continent x1 medium soft. No further BMs documented. 03/14/2017 at 4:39 AM, nurses note states in part: Digestive findings: complained of nausea, distention, and constipation. Abdominal pain: (mild pain). Abdomen: firm distended. Bowel Sounds: bowel sounds present all quadrants. Stool: none. Action: suppository given. R11 is now voicing to staff that he feels nauseated and there is distention. The nurse notes distention and firmness to R11's abdomen, which are new findings. There is no documentation to indicate the physician was notified regarding R11's nausea, firmness, and distention or that he has not had a BM at this time. On 03/14/2017 at 9:34 AM, call placed to physician regarding resident has not had a bowel movement since admit, has had milk of mag, this AM had a suppository and a fleet enema, with no results, bowel sounds active, states he is uncomfortable, refused medications, did physical therapy, requesting order for magnisum (SIC) [MEDICATION NAME] and prn [MEDICATION NAME], awaiting call back. Please note this is the first time any staff member from the facility contacted the physician regarding R11 not having a BM. 03/14/2017 at 1:00 PM, return call from physician result: new orders received and noted 03/14/2017 1) [MEDICATION NAME] 1 tablespoon daily for constipation. 2) Magnesium [MEDICATION NAME] 1 bottle daily for 2 days for constipation. R11's nursing note dated 03/14/2017, at 2:20 PM, states in part: Bowel sounds: bowel sounds present all quadrants this AM. Abdomen: Distended. Digestive findings: states he is uncomfortable awaiting magnesium [MEDICATION NAME]. R11 Medication Administration Record [REDACTED]. R11's Nutrition consult/assessment on 03/14/2017,at 3:22 PM, states in part: .Resident is refusing meals today, however, was previously eating 100% of his meals. He is constipated and uncomfortable at this time .discussed food choices that are higher in fiber to relieve constipation while he is here including oatmeal, bran flakes, fruits, vegetables, power pudding, and prune juice .will continue to monitor resident to see if his constipation is relieved, if not, will follow up with resident for nutrition intervention On 03/14/2017, R11 refused to eat Breakfast, Lunch and Supper. 03/14/2017 at 7:40 PM, nurses note states in part: Digestive findings: resident has had MOM x 3 days and bowel meds today with BM no result. Abdomen is firm and distended. Abdomen assessment is tender in the RUQ and firm and not able to auscultate bowel sounds. States he is no longer passing gas. Ate no supper. Drank the magnesium [MEDICATION NAME] this PM at 3 PM. 03/14/2017 at 7:43 PM, physician contact note states: change in condition as charted and was given an update - here for rehab following pneumonia and now complicated by no BM for 4 to 5 days prior to arrival with bowel meds being given daily since arriving here. Now abdomen firm and distended and not able to auscultate bowel sounds. No emesis and states he just doesn't feel hungry. Result: new orders received and noted 03/14/2017 Transfer to the ER by ambulance for eval and treatment. On 3/14/2017, R11 was sent to the Hospital and then transferred to another hospital on [DATE]. Hospital face sheet states: admitted : 03/16/2017 Diagnosis/complaint: Small Bowel obstruction 03/16/2017 Hospital Admission History & Physical indicates: on 3/10/2017 R11 was discharged to the nursing home on [MEDICATION NAME] and developed severe constipation and unable to move his bowels despite laxatives. He was readmitted on ,[DATE] to (Hospital name) where a CT scan demonstrated extensive stool with loss of normal haustral markings with significant distention of the proximal colon measuring up to 9 cm. there was a partial small bowel obstruction and a rectus sheath hematoma. Six attempts for a Nasogastric tube were unsuccessful including an attempt by the surgeon. He was treated with enemas without success. It was felt that he had olgivies syndrome and needed decompressive colonoscopy and was transferred.He complains of diffuse abdominal pain and distention. He passes some gas but has not had a BM in over a week. Admission status: patients presenting symptoms include abdominal pain, worrisome physical exam findings of distended abdomen.Abdomen with hypoactive bowel sounds, distended, tense, colonoscopy today for colonic decompression. On 03/17/2017 at 1:34 PM, Hospital procedure indicates: pre-op Diagnosis: [REDACTED]. Post-op Diagnosis: [REDACTED]. Moderately severe sigmoid [DIAGNOSES REDACTED]. .He has not had a BM for 1 week and is not currently passing [MEDICATION NAME] A digital exam was performed. The adult colonoscope was inserted into the rectum and advanced to the sigmoid colon at 20cm. Solid stool encountered which could not be traversed with the scope. Scope was withdrawn .pediatric gastroscope was inserted area could not be traversed with smaller diameter scope .Findings: Large and small-mouth diverticula in sigmoid colon, not bleeding. Solid stool at 20cm, which could not be [MEDICATION NAME] with both adult colonoscope and gastroscope. On 03/18/2017, Hospital consult indicates: discharged to a nursing home, where he developed severe constipation. He was readmitted to the hospital on 3/15 where imaging studies demonstrated extensive stool throughout the colon distention of proximal colon, measuring up to 9cm .underwent attempted colonoscopy. However, due to the high fecal load, this was not possible. He has been undergoing enemas every 6 hours, when earlier in the evening he developed worsening abdominal distention and pain .he has clinical and radiological evidence of a perforated viscus. Patient will require emergent laparotomy, likely bowel resection, and ostomy .he had a colonoscopy attempted, could not get pass 20 cm from impacted stool. It was real thickened . On 03/19/2017, Total abdominal colectomy, Hospital procedure note states in part: .Preoperative Diagnosis: [REDACTED]. Postoperative Diagnosis: [REDACTED]. murky fluid came out of the pelvis .descending colon was full of stool, went down in the mid rectum and here was the rectum was small (SIC). Above this area, the rectum had full of stool all the way to at least his proximal ascending colon and was full of gas beyond that. 03/30/2017, R11's Physician discharge summary states in part: .admission Diagnosis: [REDACTED].rupture of bowel, S/P [MEDICAL CONDITION], Ogilvie's Syndrome, Ileus, Rectus Sheath Hematoma . 3/30/2017, R11 was readmitted to the facility with [DIAGNOSES REDACTED]. On 06/14/2017 at 2:40PM, Surveyor interviewed Registered Nurse (RN) C regarding R11. RN C referred Surveyor to Director of Nursing (DON) B regarding information on R11. On 06/14/2017 at 3:00 PM, Surveyor interviewed DON B regarding R11. DON B remembers giving R11 a lot of bowel preps and at times, he did not want it. DON B indicated she would expect nurses to call physician on Monday (3/13/17) related to 3/11/17's order, if not before Monday (3/12/17). DON B indicated the Facility has standing orders related to bowel care and expects nurses to follow it. DON B stated, Call physician, indicated she expected staff to call the physician if a Resident still has not had a bowel movement. On 06/15/17 at 12:37 PM, Surveyor interviewed DON B over the phone regarding R11. DON B indicated she would expect nurses to look, listen and feel to inspect abdomen in general, auscultate bowel sounds and check for [MEDICAL CONDITION]. DON B stated yes, indicating expected nurses to document if bowel sounds were hyperactive (loud and extremely active) or hypoactive (reduction in the loudness, tone, or regularity of the sounds). DON B stated yes, indicating that she expects staff to notify a physician with abdominal firmness and distention. On 06/15/2017 2:57 PM, DON B provided Surveyor with additional information on [DIAGNOSES REDACTED], which states in part: .the symptoms of [DIAGNOSES REDACTED] mimic those of mechanical obstruction of the colon, but no such physical obstruction is present .[DIAGNOSES REDACTED] can be managed with conservative treatment, but if unrecognized and untreated can lead to serious, potentially-life threatening complications . Please note that per the hospital records, it's indicated that R11 had a stool blockage due to [DIAGNOSES REDACTED].

Based on observation and interview, the facility did not ensure expiration dates were included on the medication cassettes for 4 of 4 (R12, R13, R15, and R16) residents reviewed on the medication observation. R12, R13, R15, and R16's medication cassettes did not include expiration dates. This is evidenced by: 483.45(g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. DHS 132.65 (6) (b) 8. 'Labeling medications.' Prescription medications shall be labeled with the expiration date and as required by s. 450.11 (4), stats. Non-prescription medications shall be labeled with the name of the medication, directions for use, the expiration date, and the name of the resident taking the medication. On 6/13/17 at 8:08 AM, Surveyor observed the medication pass task and noted that R12, R13, R15, and R16's medications cassette's did not include an expiration date. On 6/13/17 at 10:15 AM, Surveyor interviewed Director of Nursing (DON) B regarding the medication cassettes and if the medication label should contain an expiration date. DON B indicated she was not sure and would verify with pharmacy and get back to the Surveyor. On 6/13/17 at 1:45 PM, Pharmacy Director (Pharm Dir.) E and Pharmacy Consultant (Pharm Cons.) F asked to speak with Surveyor. Surveyor asked Pharm E if expiration dates should be included on the Resident medication cassettes. Pharm E indicated that expiration dates are managed by the pharmacy. Pharm F indicated that the pharmacy will check the medications and they are good for a year. Surveyor asked how the nurse could verify the expiration date of the medication she would be administering. Pharm E indicated that the pharmacy knows the expiration dates. Pharm F indicated that the label shows how many refills are available. Surveyor reviewed with Pharm E and Pharm F the Federal regulation. Pharm E indicated the pharmacy will now add the expiration date of the medication to the label that is placed on the cassettes.

Based on observation, interview, and record review, the facility did not ensure that a resident who enters the Facility without a pressure injury (PI) does not develop a PI for 1(R2) of 10 residents reviewed for PI. R2 was admitted to the facility without a PI on either heel and was identified to be at risk for PI development. R2 developed an avoidable stage 2 PI while in the facility. R2's heels were observed not offloaded. This is evidenced by the following: The Quick Reference Guide entitled Pressure Ulcer Prevention, published by the National Pressure Ulcer Advisory Panel (NPUAP) in 2009, indicated to prevent pressure ulcers in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Ensure the heels are free of the surface of the bed. Using a pillow under the calves so the heels are elevated (i.e., floating) will accomplish reduction of pressure on heels. The Facility's Pressure Ulcer Prevention / Treatment Protocol, dated 10/11, includes in part: General Guidelines of Prevention of Pressure Ulcers - Heel and elbow protectors. R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R2 is his own decision maker. R2's admission skin assessment, dated 6/6/17, indicates that his skin is intact. R2's admission Braden, dated 6/1/17, scored an 18 which indicates R2 is at risk for PI development. R2's Braden, dated 6/7/17, scored a 20 which indicates R2 is at low risk for PI development. (Of note: this Braden was done after R2 developed a stage 2 PI.) R2 was placed on a pressure reduction mattress upon admission and remained on the same mattress. R2's Comprehensive Care Plan Potential for Tissue integrity impairment, dated 6/1/17, includes in part: Decrease in mobility, related to skin tear. Interventions include: assess skin, assess nutrition, keep MD (medical doctor) informed. Follow medical plan for treatment. Maintain adequate hydration. Intervention added 6/7/17, Nurse aide - Keep skin clean and dry. Pressure reduction mattress. Pressure reduction cushion. Inspect skin daily. Report changes. R2 to wear blue pressure protection boot to Left foot when lying down. (Of note: R2's original skin care plan did not include off -loading heels.) Nursing notes dated 6/7/17, at 4:45 AM, per Registered Nurse (RN) K, includes in part: Skin problems: Intact fluid filled blister to lateral side of left heel 5cm (centimeter) x 4 cm. Blue boot provided for heel protection while lying in bed. Nursing notes dated 6/7/17, at 6:26 AM, per RN K, includes in part: Skin problems: blister area to heel is unstageable PI. R2 believes it may have been caused by his shoe rubbing. Physician Communication Fax Data Sheet, dated 6/7/17, at 6:36 AM, includes in part: R2 has intact blister 5 cm x 4 cm to lateral side of Left heel. Nursing will continue to monitor until healed. Please fax or call with any new orders. Returned fax indicates the physician agrees with the plan of care. Nursing notes, dated 6/7/17, at 10:32AM, per RN H, includes in part: General skin condition: pale, dry, warm, intact fluid filled blister to Left heel. At this time, only have R2 wear gripper socks. Therapy is aware. On 6/12/17 at 11:00 AM, Surveyor observed R2 had a blue boot on his window ledge during the initial tour of the Facility. R2 was sitting in his recliner chair with his legs elevated and was wearing tight appearing gripper socks. R2 was observed to have [MEDICAL CONDITION] in his bilateral ankles/ feet. R2 commented to Surveyor he has a blister on his Left heel and it hurts. Surveyor asked R2 if he had the blister prior to his admission. R2 indicted no. On 6/12/17 at 1:00 PM, Surveyor observed R2 sitting in his wheelchair in the dining room with gripper socks on his feet and his feet were on the floor. Family Member (FM) G was sitting next to R2 in the dining room. On 6/12/17 at 2:20 PM, Surveyor observed R2 sitting in his recliner chair with his legs elevated wearing tight appearing gripper socks. Surveyor asked Certified Nursing Assistant (CNA) J to remove R2's Left gripper sock. CNA J removed R2's gripper sock. Surveyor noted indentation on R2's Left ankle and a large fluid filled blister on R2's Left lateral heel that extends to bottom of his heel. FM G was in R2's room and indicated to Surveyor R2 did not have that blister before he was admitted to the Facility. FM G indicated the Facility gripper socks are too tight and she requested the Facility cut them. FM G indicated the facility would not cut the gripper socks so she brought in a pair of her gripper socks and cut them. FM G indicated that R2's ankles are very swollen and the gripper socks leave indentations. Surveyor asked R2 about the blue boot on his window ledge. R2 indicated that he wears it at night but does not like to as it causes pain from pressing on the blister. FM G indicated that R2 used to wear shoes and once the blister developed the Facility told R2 he could not wear his shoes any longer. On 6/13/17 at 8:00 AM, Surveyor observed R2 sitting in his wheelchair finishing activities of daily living with an Occupational Therapist. R2 was wearing gripper socks and his feet were on the floor. R2 was observed sliding his feet back and forth on the floor. On 6/13/17 at 8:12 AM, Surveyor observed R2 sitting in his wheelchair in the dining room wearing gripper socks with his feet on the floor. On 6/13/17 at 8:45 AM, Surveyor observed R2 sitting in his wheelchair in the dining room wearing gripper socks with his feet on the floor. On 6/13/17 at 9:45 AM, Surveyor observed R2 sitting in his wheelchair in his room wearing gripper socks with his feet on the floor. Surveyor asked RN C to come to R2's room. Surveyor asked RN C if R2's feet are offloaded. RN C indicated no. Surveyor asked RN C if R2's feet should be offloaded. RN C indicated yes, they should be. RN C asked R2 if she could take the pressure off of R2's heels. R2 indicated his left [MEDICAL CONDITION] aches. RN C indicated the facility took R2's shoes away as the shoes were too tight. Surveyor asked RN C what the treatment was for R2's blister. RN C indicated offloading and monitoring. Surveyor asked RN C if they are using skin prep. RN C indicated that she has not thought about that. Surveyor asked RN C what standards of practice the Facility follows for PI. RN C indicated the Facility follows NPUAP. (Of note: RN C is the facility WCC nurse.) Nursing notes dated 6/13/17, at 11:24 AM, per RN L, includes in part: Teaching done: Spoke with R2 and FM G regarding offloading pressure from his PI on his Left heel. Spoke with therapy and they agree that R2 should wear the blue boots at all times except for transfers and walking. R2 was somewhat reluctant but advised him that the boot would protect the wound from opening up and then getting infected. R2 agreed to wear the blue boots. On 6/14/17 at 7:55 AM, Surveyor observed R2 sitting in his wheelchair in the dining room with gripper socks on and his feet on the floor. On 6/14/17 at 7:58 AM, Surveyor observed R2 sitting in his wheelchair in the dining room with gripper socks on and his feet on the floor. CNA I assisted R2 back to his room. Surveyor followed and asked CNA I why she returned R2 to his room. CNA I indicated that R2 now has to wear the blue boots at all times. Surveyor observed white padding around R2's ankle. CNA I indicated the Facility is now padding R2's blister. CNA I noted one of the blue boots had a tear along the bottom and called RN H to the room. RN H removed the gripper sock from R2's left foot and re padded the blister on the Left lateral and base of left foot. RN H placed facility gripper socks on R2's Left foot. Surveyor asked RN H if the gripper socks are causing pressure to R2 ankles. RN H indicated she could put the yellow gripper socks on which are larger in size. RN H re-applied the padding to R2's left heel leaving a portion of the blister exposed. CNA I placed a yellow gripper sock followed by the blue boot on R2's Left heel. R2 developed an avoidable stage 2 PI to his Left heel and was identified as at risk for PI development upon admit. However, the facility did not implement current standards of practice such as floating heels to prevent PI development.

Based on interview, observation, and record review, the facility has not maintained an environment that enhances residents' quality of life with respect for staff treatment for 1(R8) of 11 residents reviewed. The facility was aware that R8 voiced concerns of being rushed and spoken to in a short tone of voice which increased his anxiety. This is evidenced by: Surveyor requested an investigation for R8's concerns. The facility could not provide an investigation. R8's [DIAGNOSES REDACTED]. R8's Brief Interview for Mental Status (BIMS), dated 5/20/17, scored a 13 indicating that R8 is cognitively intact. R8 indicated that at his previous stay there was conflict. SO (Significant Other) N indicated that Certified Nursing Assistant (CNA) M was very pushy and bossy to R8. R8 indicated that he has trouble breathing and it takes longer to do things. R8 indicated CNA M told R8 what to do and was bossy. SO N and R8 indicated they reported this to Registered Nurse (RN) H. R8 indicated that CNA M could not come into his room any longer. On 6/14/17 at 8:10 AM, Surveyor interviewed RN H regarding the concern with R8 and CNA M. RN H indicated that SO N reported to her CNA M was snippy and RN H reported this to Director of Nursing (DON) B. RN H indicated she asked R8 if he wanted to file a complaint. RN H indicated R8 did not want to file a complaint. RN H indicated that she told CNA M not to go into R8's room. RN H indicated if R8 feels rushed he will get anxious. RN H indicated CNA M rushed R8 and made him nervous. RN H indicated R8 and CNA M needed a cooling off period as RN H felt this was a personality conflict. RN H had CNA M apologize to R8. RN H indicated that DON B would follow up with CNA M as it was a mutual thing and they both needed space. On 6/14/17 at 11:35 AM, Surveyor interviewed R8 regarding how it made him feel when CNA M was being snippy, pushy, and bossy with him. R8 indicated that it made him feel sad. R8 indicated it would make you feel sad too. R8 indicated he didn't have any say. I was told you have to do this and that. I felt down. R8 indicated that they don't have to treat me like I don't know what is going on as I still have my mind. The facility has not maintained an environment that enhances R8's quality of life with respect for staff treatment.

Based on record review and interview, the Facility did not ensure that all alleged violations involving mistreatment, neglect, or abuse are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures, and were thoroughly investigated to prevent further potential abuse for 2 (R4 and R8) of 10 out of 11 residents reviewed. R4 reported to the Certified Nursing Assistant (CNA) I that she was not happy with the care provided by CNA M. The facility was aware of this and did not report it to the Nursing Home Administrator and the state agency, nor did the facility complete a thorough investigation. R8 reported to Registered Nurse (RN) H that CNA M was rude, pushy, and bossy and he did not want her in his room. The Facility was aware of this and did not report it to the Nursing Home Administrator or the state agency, nor did the facility complete a thorough investigation into the allegation. Evidenced by: The Facility policy titled Caregiver Misconduct - Abuse, Neglect, Exploitation, Misappropriation of Property, and Injury of Unknown Origin Protocol , dated 3/17, includes in part: Policy: All nursing homes must report all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property, immediately within 24 hours to the Facility administrator and to the Division of Quality Assurance (DQA). The Facility must have evidence that all alleged violations are thoroughly investigated and must prevent further incidents while the investigation is in progress. Example 1 R4's [DIAGNOSES REDACTED]. R4's Brief Interview for Mental Status (BIMS), dated 4/3/17, scored a 15 indicating that R4 is cognitively intact. On 6/13/17 at 1:00 PM, Surveyor interviewed CNA I regarding any resident concerns she was aware of with other CNA's. CNA I indicated that CNA M is pushy, not patient with the residents, has a high anxiety level and we have to tell her to relax and take a deep breath. CNA M brings her personal issues to work with her. CNA I indicated some residents don't look forward to CNA M taking care of them. Surveyor asked who the residents were that did not look forward to CNA M caring for them. CNA I indicated R4. On 6/13/17 at 4:24 PM, Surveyor interviewed R4 regarding the care she receives from CNA's. R4 indicated that CNA M is not as helpful. R4 indicated that she is incontinent of both bowel and bladder and needs help with cares. R4 indicated that CNA M told her if she needs help with cares, then she should not be marked as independent. R4 indicated CNA M tells her others are waiting and that makes me not feel very good. R4 indicated that she will not put her call light on and wait until CNA M goes on break. CNA M indicated that she did report this to the nurse but did not want to indicate which nurse it was. R4 indicated that the Director of Nursing (DON) B did speak with her. On 6/14/17 at 8:20 AM, Surveyor interviewed CNA I regarding the concerns R4 had expressed to her. CNA I indicated one time R4 asked if CNA I was going to give R4 her shower. CNA I indicated no and said CNA M was giving the shower. CNA I indicated R4 hung her head to the side and said if it has to be that way and sighed. CNA I indicated she patted R4's arm and said I know. Surveyor asked CNA I if she reported this to anyone. CNA I indicated that the facility knows how CNA M is and she did not want to rehash it. CNA I indicated that other CNA's have gone to management with concerns with CNA M. CNA I indicated the facility knows about CNA M and we as a team even when working shorthanded, do not ask CNA M for help as CNA M gets frustrated and lets her impatience get a hold of her. On 6/14/17 at 9:50 AM, Surveyor interviewed DON B regarding R4 allegation with CNA M. DON B indicated that she can't recall and issue with R4 and CNA M. Surveyor asked DON B about the known history with CNA M. DON B indicated that there were staff personality conflicts and indicated that CNA M does best on a household versus floating to other units. Surveyor asked DON B if a resident did not look forward to a CNA working with them, lowered their head and sighed with the comment, If it has to be that way would you still have that CNA work with the resident. DON B indicated she would do something about that. Example 2 R8's [DIAGNOSES REDACTED]. R8's Brief Interview for Mental Status (BIMS) dated 5/20/17 scored a 13 indicating that R8 is cognitively intact. On 6/13/17 at 4:10 PM, Surveyor observed R8 ambulating from his bathroom to his recliner with oxygen on via concentrator. R8 sat in his recliner and was visibly slow moving and was slightly short of breath on exertion. Surveyor asked R8 once settled into the recliner if he had any concerns with staff. R8's Significant Other (SO) N was in the room. R8 indicated that at his previous stay there was a conflict with CNA M. SO N indicated that CNA M was very pushy and bossy to R8. R8 indicated that he has trouble breathing and it takes longer to do things. R8 indicated CNA M told R8 what to do and was bossy. SO N and R8 indicated they reported this to Registered Nurse (RN) H. R8 indicated that CNA M could not come into his room any longer. On 6/14/17 at 8:10 AM, Surveyor interviewed RN H regarding the concern with R8 and CNA M. RN H indicated that SO N reported to her CNA M was snippy and RN H reported this to Director of Nursing (DON) B. RN H indicated she asked R8 if he wanted to file a complaint. RN H indicated R8 did not want to file a complaint. RN H indicated that she told CNA M not to go into R8's room. RN H indicated if R8 feels rushed he will get anxious. RN H indicated CNA M rushed R8 and made him nervous. RN H indicated R8 and CNA M needed a cooling off period as RN H felt this was a personality conflict. RN H had CNA M apologize to R8. RN H indicated that DON B would follow up with CNA M as it was a mutual thing and they both needed space. On 6/14/17 at 11:35 AM, Surveyor interviewed R8 regarding how it made him feel when CNA M was being snippy, pushy, and bossy with him. R8 indicated that it made him feel sad. R8 indicated it would make you feel sad too. R8 indicated he didn't have any say. I was told you have to do this and that. I felt down. R8 indicated that they don't have to treat me like I don't know what is going on as I still have my mind. On 6/14/17 at 8:40 AM, Surveyor interviewed RN C regarding the knowledge she had with R8 and CNA M. RN C indicated that nothing came to mind and she was not aware of any issues. On 6/14/17 at 9:30 AM, RN C approached Surveyor reporting that she was not made aware of the concerns with R8 and CNA M as RN H and DON B as they felt it was handled. RN C indicated RN H and DON B resolved the issue. On 6/14/17 at 9:50 AM, Surveyor interviewed DON B regarding R8 allegation with CNA M. DON B indicated that she did not recall any concerns with R8. DON B indicated RN H should have reported this concern to her as it could be considered abuse. DON B indicated that RN H should have started an investigation. On 6/14/17 at 10:45 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding the allegation with R8 and CNA M. NHA A indicated that nothing was brought to his attention with concerns for R4, R8, or CNA M. NHA A indicated he was aware of staff conflicts with CNA M. NHA A indicated that he would have investigated this. On 6/15/17 at 1:15 PM, Surveyor received additional information from the facility an email from RH H to DON B dated 3/26/17, which includes in part; RN H called to R8's room, as CNA M was rushing him, being very short in her tone. R8 had asked for the urinal and did not make it and urinated on the floor. R8 and SO N indicated CNA M's mannerism makes R8 nervous and this has happened on more than one occasion. RN H indicated that different staff would be caring for him the rest of the day. RN H spoke with CNA M. CNA M reported she did hurry with R8 and her tone may have come of short. RN H encouraged CNA M to apologize to R8 which she did. RN H told CNA M that if this happens again the DON B will not be so understanding. Documentation from DON B on 3/27/17 includes in part; R8 feels safe and indicated CNA M was hurried but not abusive. R8 did not want anyone to be in trouble. DON B indicated this was a teachable moment that we take concerns seriously and want our residents treated with respect. The facility did not ensure that all alleged violations involving mistreatment, neglect, or abuse, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures, and were thoroughly investigated to prevent further potential abuse.

Based on record review and interview, the Facility did not consult with the resident's physician when weight loss was noted for 1 (R2) of 11 residents reviewed for weight loss/gain. R2 lost 7.6 pounds in 10 days and has a physician's orders [REDACTED]. The facility did not consult with R2's physician when the weight loss was identified. Evidenced by the following: The Facility's Resident Change of Condition policy, reviewed 3/17, includes in part: D. Weight loss/gain. 1. Equal to or greater than 5% in 30 days. 2. Equal to or greater than 10% in 180 days. R2's physician's orders [REDACTED]. On 6/13/17 at 2:00 PM, Surveyor reviewed R2's weights. 6/2/17 - 257, 6/12/17 - 249.4 (7.6 lb. loss in 10 days). Nursing notes, dated 6/13/17, include in part: weight down from admit on 6/2/17. Will ask medical doctor (MD) to review and ask if any adjustments are needed. On 6/14/17 at 2:50 PM, Surveyor interviewed Director of Nursing (DON) B regarding R2's 7.6 pound weight loss in 10 days and the physician's orders [REDACTED]. Surveyor asked DON B if R2's 7.6 pound weight loss should have been reported to R2's physician. DON B indicated absolutely the physician should have been called. The facility sent more documentation to indicate that the physician was left a message about the weight loss on 6/13/17 but there is no documentation that the facility consulted with the physician as ordered for a loss of 7.6 pounds in 10 days.