Every finding on record at Soldiers Grove Health Services

Based on interview and record review, the facility did not ensure each resident receives the necessary care and services in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 13 sampled residents (R20) resulting in actual harm. R20 was self-transferring multiple times and on the eighth attempt, suffered an unwitnessed fall. The facility failed to provide an assessment completed by an RN (Registered Nurse) or with RN oversight at the time of the fall. The facility failed to notify the physician timely of the fall, failed to relay all of R20's symptoms to physician and DON B (Director of Nursing) at the time of the fall, and failed to notify physician of changes of condition following the fall. R20 was found to have a left acetabular (hip joint socket) fracture. Evidenced by:Facility policy, titled Change in Condition of the Resident, reviewed 9/20/22, includes, in part: .When a resident presents with a possible change in condition, after a fall or other possible trauma, or noted changes in mental or physical functioning: assess the resident's need for immediate care/medical attention. Provide emergency care as needed. Assessment/evaluation could include, but is not limited to, the following: vital signs, oxygen saturation, blood glucose level .lacerations - amount of bleeding drainage, size/depth of wound, dressings/condition of - if in place.Swelling, edema, discoloration.pain- location, type, intensity, duration, causative factors . alteration in level of consciousness, ability to respond . bowel and bladder control, sensory weakness or change.speech disorder.abdominal spasms or pain . Flushing, cyanosis, blanching.Abduction, adduction, shortening or improper position of extremities.Notify resident's physician.Immediate notification for any symptoms and signs or apparent discomfort, or a marked change in relation to usual symptoms and signs, or unrelieved by measures already prescribed requires a phone call to the provider . Do not fax for issues requiring immediate notification.Non immediate notification: Notifications that do not require immediate consultation with physician . Notify resident's family/responsible party as applicable and in accordance with resident's wishes. Monitor resident's condition frequently until stable or transported to a higher level of care .ensure resident's change in condition is included on the 24 hour report to be reviewed later . Documentation needs to include, but is not limited to the following: description of change in condition noted and assessment or observation of findings, emergency care provided, notification of physician, notification of appropriate party .According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants.(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.R20 admitted to the facility initially on 10/14/24 and has diagnoses that include paroxysmal atrial fibrillation (irregular rapid heart rate), unspecified fracture of left acetabulum (hip joint socket), acute kidney failure, hypothyroidism, benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate gland that can cause urination difficulty), other obstructive and reflux uropathy (abnormality of the urinary tract).R20's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/20/25, indicates R20's cognition is severely impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Section GG of this assessment indicates R20 needed substantial/maximum assist for toileting, going from sit to stand, and supervision or touching assist for walking.R20's Fall/Risk Management Report titled Un-witnessed Fall, dated 6/29/25 05:00, includes in part: . Nursing description: Resident bed alarm sounding in room. As staff respond to alarm, staff hear a loud crash. Find resident on the floor, he had fallen into an old record cupboard along the wall on his roommate's side of the room. Resident lying on his left side, feet were toward the bed, head toward roommate side of room. [NAME] was at heater, facing the door. Seeming resident was walking toward the bathroom and had collapsed and went to the left of walker. [NAME] was left standing by itself. Resident was pale and diaphoretic (excessive sweating). Noted to have some slurred speech at the initial response time. Quick stroke assessment was negative. Tongue came out straight, equal hand grip strength. Resident complaining of pain to left elbow and left shoulder at this time. Resident description: Resident states that he was going to the bathroom. However resident has made the walk multiple times this shift to the bathroom and knows where to go, even in the dark. Resident was walking in the opposite direction at the time of his fall.Immediate Action Taken, Description: Resident VS (vital signs) taken immediately. Stroke assessment completed. Rapid trauma assessment completed. No complaints of pain to chest/ribs, abdomen or hips. No external/internal rotation to feet, no limb shortening of lower extremities present. Resident assisted to the bed with 3 staff members. Skin assessment completed. Skin tear unable to be approximated, wound covered with ABD and wrapped with kerlix at this time. Resident taken to Hospital? NoIt is important to note the nurse who prepared this report and conducted the assessments is a Licensed Practical Nurse (LPN) (LPN H). R20 was moved from the floor without an RN assessment. There is no evidence ROM was evaluated prior to moving R20.Additional information provided by facility via email on 7/23/25 indicates DON B (Director of Nursing) was updated at 6:05 AM regarding the fall incident. (Of note, this is an hour after R20 fell and this is not documented in R20's falls note.)6/29/25 Neuro check form indicates 5:00 AM pain is a 56/29/25 Neuro check form indicates 5:35 AM pain is a 5Surveyor reviewed the fax that was sent to the provider by LPN H dated 6/29/25 and sent at 6:34 AM. Fax states, in part: : .Resident had an unwitnessed fall this morning. Attempting to take self to bathroom for the 8th time tonight. Resident more confused, walking opposite direction from bathroom, resident fell into a cupboard on roommate's side of room. Skin tear to left elbow unable to be approximated. Wound covered with ABD (antibiotic ointment) and Kerlix. C/o pain to tear and left shoulder. Would you like any labs or Xrays of shoulders?It is important to note there is no mention in this fax of resident being pale, diaphoretic, or having slurred speech as it states in the risk management report. There is no mention of the nurse doing a stroke assessment or rapid trauma assessment in the fax.R20's documentation indicated the following:On 6/29/25 at 6:18 AM, Note text: Resident had a fall this morning in room as he was transferring self and taking self to bathroom. Resident had done this same thing 7 other times this shift. This marking his 8th attempt. Resident was walking opposite of bathroom and had fallen into a cupboard on his roommate's side of the room breaking it. Resident has a skin tear to left elbow and left shoulder. Fax sent to PCP (primary care physician) re: pain to areas and multiple attempts.It is important to note that 6/29/25 (date of fall) was on a Sunday. It's also important to note there is no mention of the nurse doing range of motion assessment to upper and lower extremities in this progress note. On 6/29/25 Neuro check form indicates at 7:35 AM (0735) R20 rated his pain at a 5On 6/29/25 at 8:13 AM, Note text: POA/wife (power of attorney) updated of fall at 0800.On 6/29/25 at 8:28 AM, Note text: On call MD [Doctor's name] contacted and updated of resident fall. D/T resident c/o pain to left shoulder and rib area, verbal order given for X-rays. [Doctor's name] asks that resident respiratory status be monitored and report any SOB (shortness of breath) or distress. Verbal order also given for UA (urinalysis) and urine culture d/t resident more frequent urination which results in resident self transferring and more frequent incontinence. Orders placed and POA updated.On 6/29/25 at 10:21 AM, Note text: Floor nurse called into resident room by staff. CNA's (certified nursing assistants) were assisting resident when dried blood was noted on back of shirt. Resident was c/o pain and burning to area. 3 open areas were noted to resident left upper back. One open area was small in size and superficial abrasion. Second measured .75 cm x 1.5 cm. Third measured 8 cm x 1 cm. Area was cleansed. Triple antibiotic ointment applied, and area covered with nonwoven gauze.Of note, there is no mention of contacting R20's physician/provider regarding open areas noted to R20's back.6/29/25 Neuro check form indicates at 10:36 AM Pain rated at a 5.On 6/29/25 at 11:03 AM, Nurses note indicates PRN Tylenol given.6/29/25 Neuro check form indicates at 3:35PM pain rated at a 7.6/29/25 Neuro check form indicates at 6:05 PM pain rated at a 4. On 6/29/25 at 6:47 PM, Note text: At 18:30, went into room and resident lying in bed. POA, son and daughter in room. No S/SX (signs and symptoms) of pain when visualizing resident. Lung sounds clear throughout. No SOB noted. O2 sat (saturation) is 92% on RA (room air). Pulse 84 regular. Resident has AROM (active range of motion) to right UE (upper extremities) and LE (lower extremities). When asked to move left arm, resident refuses. When asked to move LLE (left lower extremities), resident is able to move left leg left and right. Unwilling to move or allow writer to move LLE up or down. No internal or external rotation noted to BLE (bilateral lower extremities). No shortening noted. Family states that X ray was for rib and hip. Informed family that the order was for shoulder and rib due to pain after the fall. Family stated, Well maybe they got the hip too with that X ray. When auscultating lung sounds, resident complained of pain when touching left rib area. Questioned if resident would like something for pain and he stated yes. PRN (as needed) Tylenol given. POA questioning results of X ray and informed POA that no results yet from imaging and will call company to see where they are at with the results. POA voiced appreciation for the update. Placed call to mobile imaging at 1845 and spoke with tech stating that results are not in and that they will fax results when available. Confirmed fax number with tech.It is important to note this is the first assessment completed by an RN (Registered Nurse) on R20 since his fall over 13 hours prior. Initial assessment was completed by LPN H. R20 is refusing to move his left arm and leg during ROM assessment, this is a change in R20's status. No evidence a physician/provider was notified.6/29/25 at 7:35 PM (1935) indicates PRN (as needed) Tylenol given, follow up pain evaluation indicated as 0.6/30/25 at 1:16 AM, Note text: The current status is resting in bed. C/o (complains of) pain when moving and touching him PRN Tylenol given. Continue to monitor.Of note: R20 continued to have pain when being moved or touched, no evidence a physician/provider was updated. There is no documentation of an assessment on Night shift. 6/30/25 at 2:04 AM, Note text: Received X ray results from (imaging company name). Left X ray, shoulder. There is no evidence of acute fracture or dislocation. X ray of ribs, unilateral; include PA (posterior anterior) chest. There is no left rib fractures. No evidence of acute cardiopulmonary disease. No pneumothorax. X ray results faxed to PCP.6/30/25 at 0229 (2:29AM) Neuro check form indicates Tylenol ES (extra strength) given Pain rating of a 6 with grimaces and withdraws being marked as yes.6/30/25 at 6:48 AM, Note text: Resident pain level every shift use PAINAD if resident unable to verbalize pain. Yells at the slightest movement. Pain appears to be in left upper leg or hip.It is important to note R20 yells at the slightest movement, there is no evidence of staff contacting a physician with this increase in pain. There is no RN assessment even though there is increased pain noted after R20 sustained a fall on 6/29/25. 6/30/25 at 8:51 AM, Note text: Resident is laying in bed with eyes partly open and readily responds to voice. Resident took his medications this morning but refused breakfast. He refuses to sit up or change position. Resident complains of pain in his left hip, leg, and or heel. Tylenol was ineffective in pain management. Family would like to get X rays of those areas. Resident yells in pain before he even gets touched. Resident has wounds that are draining onto the bed sheets and refuses to let us touch them. Resident is more confused that [sic] usual. Discussed the resident status with POA (wife) and she agreed that he needs to be sent to the ER to get full medical care. POA requests that he should not be given oxycodone (her usual request). Called [Doctors name] at the [NAME] clinic and left message requesting order for transfer to ER.Of note, R20's POA indicated wanting him sent to the ER, facility staff did not send R20 right away, staff waited for an order from the clinic.6/30/25 at 9:01 AM, Note text: Nurse [Nurses name] from [NAME] Clinic called and communicated orders from [Doctors name] for transfer to ER.6/30/25 at 9:28 AM, Note text: Called [NAME] County [NAME] requesting a non-emergent transfer to the ER. Called ER nurse and provided nurse-to-nurse report.6/30/25 at 9:51 AM, Note text: Resident was taken to ER via ambulance. Wife notified.6/30/25 at 2:39 PM, Note text: Hip fracture from fall.6/30/25 at 5:01 PM, Note text: hospitalized . R20's Emergency Department Notes/Hospital Record, dated 6/30/25 at 10:17 AM, includes in part: .Patient presenting to the emergency department following a fall at the nursing home 3 days ago with the patient having persistent severe pain, inability to ambulate, and worsening confusion over the past 2-3 days.Patient given IV pain medications due to concern for underlying hip fracture.Elbow x-ray also obtained prior to obtaining CT scan of the abdomen and pelvis given patient's complaints, however showing no evidence of fracture. CT scan of the abdomen and pelvis returning with concern for bladder thickening and cystitis, new left-sided acetabular fracture of the posterior and anterior pillars, as well as new L3 compression fracture.Patient was discussed with on-call orthopedic surgeon, [surgeon's name], with recommendation for conservative management of acetabular fracture given patient's poor bone quality, not surgical candidate.recommended 6 weeks non weight bearing.Admit for pain management adjustment. With a non-operable hip fracture in a frail 92 year, particularly one who has had poor oral intake in the last two days, the prognosis is concerning. R20's CT (computed tomography) Abdomen Pelvis with contrast Report, dated 6/30/25 at 1:19 PM, includes in part: .Osseous structures: Old healed fracture deformities at the left superior and inferior pubic rami. Acute mildly comminuted and mildly displaced left acetabular fracture with involvement of both the anterior and posterior columns. Stable chronic moderate to severe compression fracture at T11. Newly visualized and likely acute moderate compression fracture at the L3 vertebral body.Of note, R20 went greater than 24 hours with a broken mildly comminuted (bone breaks into 3 or more pieces caused by high forced accidents or trauma i.e. falls) and mildly displaced (bone fragments are not properly aligned) left acetabular (hip socket) fracture.On 7/21/25, Surveyor attempted to contact the 2 CNAs who were on duty the time of R20's fall. Surveyor left voicemail with no return calls.On 7/21/25 at 11:38 AM, Surveyor interviewed CNA J and asked if R20 self-transfers and what interventions are in place for R20 to prevent falls. CNA J indicated yes, R20 self-transfers and he has bed and chair alarms and they take him to the bathroom every 2 hours minimum.On 7/21/25 at 11:41 AM, Surveyor interviewed CNA K and asked if R20 self-transfers and what fall interventions are in place for this resident. CNA K indicated R20 does self-transfer, not as often as he used to before his fall but he does still self-transfer some. CNA K also indicated they take him to the bathroom every 2 hours minimum but he will let staff know when he has to go when he is in common areas. CNA K indicated he has fall alarms, bed in low position, chair at bedside, and stated he likes to sit in the sun in the dayroom.On 7/21/25 at 10:44 AM via phone, Surveyor interviewed LPN I regarding R20's fall. LPN I stated she started her shift after R20's fall. She stated it's common for R20 to self-transfer and he has bed and chair alarms and staff should be doing frequent checks as much as they can. LPN I stated LPN H did hip assessment on lower extremities and nothing hurt R20 at that time. LPN I indicated the assessment should be in R20's progress notes. Surveyor reviewed R20's progress notes and there is no mention of assessments completed in LPN H's progress notes from the fall. Surveyor observed hip assessment in fall report but not progress notes.Surveyor attempted to contact LPN H three times via phone. Surveyor was not successful in reaching LPN H.Surveyor checked the schedules for 6/28/25 (into 6/29) and 6/29/25 (into 6/30) and there were no RNs on duty on night shift either of those days.On 7/17/25 at 2:59 PM, Surveyor interviewed DON B (Director of Nursing) who indicated if no RN is on the schedule, she is on call 24/7. In a follow up interview with DON B and EM L on 7/21/25 at 12:29 PM, DON B indicated she would have expected staff to have increased supervision for R20 after he was self-transferring 7-8 times and temporary interventions. DON B indicated LPN did the assessments on R20 and called DON B after she completed them, they were done without RN oversight. DON B stated LPN H called her after the fall and told her what happened and about rotation and ROM, didn't have concerns. Surveyor asked if LPNs could perform assessments and DON B stated, They can collect data. She would have expected staff to put assessments completed in the resident's progress notes. Surveyor asked DON B how staff got R20 off of the floor after his fall. DON B stated it's not in LPN's documentation but after talking with staff, it was with a Hoyer lift. DON B indicated this should have been documented. DON B stated LPN H did not inform DON B of R20's slurred speech, being pale and diaphoretic when she called her at 6:05 AM after R20's fall. DON B indicated she would have expected an immediate phone call to the physician instead of a fax with those symptoms. Surveyor asked DON B who did the stroke assessment on R20 and stated LPN H. DON B indicated an RN should do stroke assessments. Surveyor asked DON B if any staff education was done after this incident, and she indicated not that she's aware of.R20 was self-transferring multiple times in one shift and had an unwitnessed fall. R20 had a change in condition without an RN assessment or continued monitoring. R20's provider was not updated with R20's changes in condition resulting in a delay in treatment and R20 was found to have a left acetabular (hip joint socket) fracture.

Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (R20) reviewed for falls resulting in actual harm.R20 was self-transferring multiple times and on the eighth attempt, suffered an unwitnessed fall. The facility failed to provide temporary interventions to address the self-transferring. R20 was found to have a left acetabular (hip joint socket) fracture.This is evidenced by:Facility policy, titled Fall Prevention and Management Guidelines, reviewed and revised on 7/18/24, states in part; Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized plan of care to minimize the likelihood of falls or reduce the possibility/severity of injury. A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not because of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere . When any resident experiences a fall, the facility will complete a post fall assessment and review: physical assessment with vital signs, neuro checks for any unwitnessed fall or witnessed fall where resident hits their head.alert MD of any abnormal findings from neuro checks - do not wait until series is completed to notify MD of abnormal findings.complete an incident report in Risk Management, notify physician and family/responsible party, review resident's care plan and update with any new interventions put in place to try to prevent additional falls, document all assessments and actions, obtain witness statements from other staff with possible knowledge or relevant information.R20 admitted to the facility initially on 10/14/24 and has diagnoses that include: paroxysmal atrial fibrillation (irregular rapid heart rate), unspecified fracture of left acetabulum (hip joint socket), acute kidney failure, hypothyroidism, benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate gland that can cause urination difficulty), and other obstructive and reflux uropathy (abnormality of the urinary tract).R20's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/20/25, indicates R20's cognition is severely impaired with a Brief Interview for Mental Status (BIMS) score of 4 out of 15. Section GG of this assessment indicates R20 needed substantial/maximum assist for toileting, going from sit to stand, and supervision or touching assist for walking.R20's Comprehensive Care Plan states in part: .Focus: At risk for falls .Interventions/Tasks: Bed in low position, date initiated: 10/14/24 . Broda chair by bedside when in bed, date initiated: 7/1/25 .Chair and bed alarms placed and check for proper functioning and placement every shift, date initiated: 5/2/25 .Encourage to transfer and change positions slowly, date initiated: 10/14/24 .FALL RISK (FYI), date initiated: 7/1/25 .Have commonly used articles within easy reach, date initiated: 10/14/24 .Reinforce need to call for assistance, date initiated: 10/14/24 .Reinforce w/c (wheelchair) safety as needed such as locking brakes, date initiated: 10/14/24 .Focus: Urinary Incontinence .Intervention/Tasks: Offer toileting every 2 hours and PRN, date initiated 1/26/25 .R20's Fall/Risk Management Report titled Unwitnessed Fall, dated 6/29/25 05:00 (5:00 AM), includes in part: . Nursing description: Resident bed alarm sounding in room. As staff respond to alarm, staff hear a loud crash. Find resident on the floor, he had fallen into an old record cupboard along the wall on his roommate's side of the room. Resident lying on his left side, feet were toward the bed, head toward roommate side of room. [NAME] was at heater, facing the door. Seeming resident was walking toward the bathroom and had collapsed and went to the left of walker. [NAME] was left standing by itself. Resident was pale and diaphoretic. Noted to have some slurred speech at the initial response time. Quick stroke assessment was negative. Tongue came out straight, equal hand grip strength. Resident complaining of pain to left elbow and left shoulder at this time. Resident description: Resident states that he was going to the bathroom. However resident has made the walk multiple times this shift to the bathroom and knows where to go, even in the dark. Resident was walking in the opposite direction at the time of his fall.Immediate Action Taken, Description: Resident VS (vital signs) taken immediately. Stroke assessment completed. Rapid trauma assessment completed. No complaints of pain to chest/ribs, abdomen or hips. No external/internal rotation to feet, no limb shortening of lower extremities present. Resident assisted to the bed with 3 staff members. Skin assessment completed. Skin tear unable to be approximated, wound covered with ABD and wrapped with kerlix at this time. Resident taken to Hospital? No.It is important to note the nurse who prepared this report and conducted the assessments is a Licensed Practical Nurse (LPN) (LPN H) and R20 was moved without an RN assessment. It's also important to note there is no mention of LPN H doing a range of motion assessment to the upper and lower extremities prior to moving R20.Additional information provided by facility via email on 7/23/25 indicates DON B (Director of Nursing) was updated at 6:05 AM regarding the fall incident. (Of note, this is an hour after R20 fell.)R20's Nurses Notes dated 6/29/25 include in part: 6:18 AM, Note text: Resident had a fall this morning in room as he was transferring self and taking self to bathroom. Resident had done this same thing 7 other times this shift. This marking his 8th attempt. Resident was walking opposite of bathroom and had fallen into a cupboard on his roommate's side of the room breaking it. Resident has a skin tear to left elbow and left shoulder. Fax sent to PCP (primary care physician) re: pain to areas and multiple attempts.It is important to note that 6/29/25 (date of fall) was on a Sunday. It's also important to note there is no mention of the nurse doing range of motion assessment to upper and lower extremities in this progress note. This note also indicates staff were aware R20 was self-transferring multiple times already that shift and there is no documentation of temporary interventions being attempted.Surveyor reviewed the fax that was sent to the provider by LPN H dated 6/29/25 and sent at 6:34 AM. Fax states, in part: : .Resident had an unwitnessed fall this morning. Attempting to take self to bathroom for the 8th time tonight. Resident more confused, walking opposite direction from bathroom, resident fell into a cupboard on roommate's side of room. Skin tear to left elbow unable to be approximated. Wound covered with ABD (antibiotic ointment) and Kerlix. C/o pain to tear and left shoulder. Would you like any labs or Xrays of shoulders?It is important to note there is no mention in this fax of resident being pale, diaphoretic, or having slurred speech as it states in the risk management report. There is no mention of the nurse doing a stroke assessment or rapid trauma assessment in the fax.8:13 AM, Note text: POA/wife (power of attorney) updated of fall at 0800.8:28 AM, Note text: On call MD [Doctor's name] contacted and updated of resident fall. D/T resident c/o pain to left shoulder and rib area, verbal order given for X-rays. [Doctor's name] asks that resident respiratory status be monitored and report any SOB (shortness of breath) or distress. Verbal order also given for UA (urinalysis) and urine culture d/t resident more frequent urination which results in resident self transferring and more frequent incontinence. Orders placed and POA updated.10:21 AM, Note text: Floor nurse called into resident room by staff. CNAs (certified nursing assistants) were assisting resident when dried blood was noted on back of shirt. Resident was c/o pain and burning to area. 3 open areas were noted to resident left upper back. One open area was small in size and superficial abrasion. Second measured .75 cm x 1.5 cm. Third measured 8 cm x 1 cm. Area was cleansed. Triple antibiotic ointment applied and area covered with nonwoven gauze.6:47 PM, Note text: At 18:30 (6:30 PM), went into room and resident lying in bed. POA, son and daughter in room. No S/SX (signs and symptoms) of pain when visualizing resident. Lung sounds clear throughout. No SOB noted. O2 sat (saturation) is 92% on RA (room air). Pulse 84 regular. Resident has AROM (active range of motion) to right UE (upper extremities) and LE (lower extremities). When asked to move left arm, resident refuses. When asked to move LLE (left lower extremity), resident is able to move left leg and right. Unwilling to move or allow writer to move LLE up or down. No internal or external rotation noted to BLE (bilateral lower extremities). No shortening noted. Family states that X ray was for rib and hip. Informed family that the order was for shoulder and rib due to pain after the fall. Family stated, Well maybe they got the hip too with that X ray. When auscultating lung sounds, resident complained of pain when touching left rib area. Questioned if resident would like something for pain and he stated yes. PRN (as needed) Tylenol given. POA questioning results of X ray and informed POA that no results yet from imaging and will call company to see where they are at with the results. POA voiced appreciation for the update. Placed call to mobile imaging at 1845 (6:45PM) and spoke with tech stating that results are not in and that they will fax results when available. Confirmed fax number with tech.It is important to note this is the first assessment completed by an RN (Registered Nurse) on R20 since his fall over 13 hours prior. Initial assessment was completed by LPN H. 6/30/25 at 1:16 AM, Note text: The current status is resting in bed. C/o (complains of) pain when moving and touching him PRN Tylenol given. Continue to monitor.6/30/25 at 2:01 AM, Note text: Call placed to daughter, (name) in regards of X ray results. Message left.6/30/25 at 2:04 AM, Note text: Received X ray results from (name of imaging company). Left X ray, shoulder. There is no evidence of acute fracture or dislocation. X ray of ribs, unilateral; include PA chest. There is no left rib fractures. No evidence of acute cardiopulmonary disease. No pneumothorax. X ray results faxed to PCP.6/30/25 at 6:48 AM, Note text: Resident pain level every shift use PAINAD if resident unable to verbalize pain. Yells at the slightest movement. Pain appears to be in left upper leg or hip.6/30/25 at 8:51 AM, Note text: Resident is laying in bed with eyes partly open and readily responds to voice. Resident took his medications this morning but refused breakfast. He refuses to sit up or change position. Resident complains of pain in his left hip, leg, and or heel. Tylenol was ineffective in pain management. Family would like to get X rays of those areas. Resident yells in pain before he even gets touched. Resident has wounds that are draining onto the bed sheets and refuses to let us touch them. Resident is more confused that [sic] usual. Discussed the resident status with POA and she agreed that he needs to be sent to the ER to get full medical care. POA requests that he should not be given oxycodone (her usual request). Called [Doctors name] at the [Clinic name] and left message requesting order for transfer to ER.6/30/25 at 9:01 AM, Note text: Nurse [Nurses name] from [name of Clinic] called and communicated orders from [Doctors name] for transfer to ER.6/30/25 at 9:28 AM, Note text: Called [County [NAME]] requesting a non-emergent transfer to the ER. Called ER nurse and provided nurse-to-nurse report.6/30/25 at 9:51 AM, Note text: Resident was taken to ER via ambulance. Wife notified.6/30/25 at 2:39 PM, Note text: Hip fracture from fall.6/30/25 at 5:01 PM, Note text: hospitalized .R20's Emergency Department Notes/Hospital Record, dated 6/30/25 at 10:17 AM, includes in part: .Patient presenting to the emergency department following a fall at the nursing home 3 days ago with the patient having persistent severe pain, inability to ambulate, and worsening confusion over the past 2-3 days.Patient given IV pain medications due to concern for underlying hip fracture.Elbow x-ray also obtained prior to obtaining CT scan of the abdomen and pelvis given patient's complaints, however showing no evidence of fracture. CT scan of the abdomen and pelvis returning with . new left-sided acetabular fracture of the posterior and anterior pillars, as well as new L3 compression fracture.Patient was discussed with on-call orthopedic surgeon, [surgeon's name], with recommendation for conservative management of acetabular fracture given patient's poor bone quality, not surgical candidate.recommended 6 weeks non weight bearing.Admit for pain management adjustment. With a non-operable hip fracture ., particularly one who has had poor oral intake in the last two days, the prognosis is concerning. R20's CT (computed tomography) Abdomen Pelvis with contrast Report, dated 6/30/25 at 1:19 PM, includes in part: .Osseous structures: Old healed fracture deformities at the left superior and inferior pubic rami. Acute mildly comminuted and mildly displaced left acetabular fracture with involvement of both the anterior and posterior columns. Stable chronic moderate to severe compression fracture at T11. Newly visualized and likely acute moderate compression fracture at the L3 vertebral body.On 7/21/25, Surveyor attempted to contact LPN H three times via phone. Surveyor was not successful in reaching LPN H.On 7/21/25, Surveyor attempted to contact the 2 CNAs who were on duty at the time of R20's fall. Surveyor was unsuccessful in reaching the 2 CNAs. On 7/21/25 at 11:38 AM, Surveyor interviewed CNA J (Certified Nursing Assistant) and asked if R20 self-transfers and what interventions are in place for R20 to prevent falls. CNA J indicated yes, R20 self-transfers and he has bed and chair alarms and they take him to the bathroom every 2 hours minimum.On 7/21/25 at 11:41 AM, Surveyor interviewed CNA K and asked if R20 self-transfers and what fall interventions are in place for this resident. CNA K indicated R20 does self-transfer, not as often as he used to before his fall, but he does still self-transfer some. CNA K also indicated they take him to the bathroom every 2 hours minimum, but he will let staff know when he has to go when he is in common areas. CNA K indicated he has fall alarms, bed in low position, chair at bedside, and stated he likes to sit in the sun in the dayroom.On 7/21/25 at 10:44 AM, via phone, Surveyor interviewed LPN I regarding R20's fall. LPN I stated she started her shift after R20's fall. She stated it's common for R20 to self-transfer and he has bed and chair alarms and staff should be doing frequent checks as much as they can. LPN I stated LPN H did hip assessment on lower extremities and nothing hurt R20 at that time. LPN I indicated the assessment should be in R20's progress notes.Surveyor reviewed R20's progress notes and there is no mention of assessments completed in LPN H's progress notes from the fall. Surveyor observed hip assessment in fall report but not progress notes.Surveyor checked the schedules for 6/28 into 6/29 and 6/29 into 6/30. There were no RNs on duty on night shift either of those days.On 7/17/25 at 2:59 PM, Surveyor interviewed DON B (Director of Nursing) who indicated if no RN is on the schedule, she is on call 24/7. In a follow up interview with DON B and EM L (Executive Manager) on 7/21/25 at 12:29 PM, DON B indicated she would have expected staff to have increased supervision for R20 after he was self-transferring 7-8 times and temporary interventions. DON B indicated LPN H did the assessments on R20 and called DON B after she completed them, they were done without RN oversight. DON B stated LPN H called her after the fall and told her what happened and about rotation and ROM, didn't have concerns. Surveyor asked if LPNs could perform assessments and DON B stated, They can collect data. She would have expected staff to put assessments completed in the resident's progress notes. Surveyor asked DON B how staff got R20 off of the floor after his fall. DON B stated it's not in the LPN's documentation but after talking with staff, it was with a Hoyer lift. DON B indicated this should have been documented. DON B stated LPN H did not inform DON B of R20's slurred speech, being pale and diaphoretic when she called her at 6:05 AM after R20's fall. DON B indicated she would have expected an immediate phone call to the physician instead of a fax with those symptoms. Surveyor asked DON B who did the stroke assessment on R20 and DON B stated LPN H. DON B indicated an RN should do stroke assessments. Surveyor asked DON B if any staff education was done after this incident and she indicated not that she's aware of.Additional information received from the facility on 7/24/25 via email with two staff statements that state in part the following: 7-23-24 Resident was up to the bathroom multiple times. Resident was offered to get up in chair but would turn look at the clock on the way back from bathroom and said it was to early. Resident had snacks at bedside also. Resident was offered to come sit in living room area resident wanted to go back to bed. (Signature). Second statement states in part: 7/24/25. 6/29/25 on the night in question, (R20's name) was up multiple times to the bathroom. Ambulated to and from bathroom (with) no c/o (complaints of) pain or discomfort. Resident also denied pain. Also refused suggestion of sitting in broda chair to come out by us. Would check his clock on his walk back from the bathroom, and state it was too early. Resident had graham crackers and H2O (water) @ (at) bedside . (Of note, no temporary interventions for increased supervision due to getting up multiple times was implemented when R20 did not agree to get up into his chair to prevent a fall.)R20 was self-transferring multiple times in a shift, the facility failed to provide temporary interventions to address the self-transferring, and on the 8th attempt, R20 had an unwitnessed fall. R20 was found to have a left acetabular (hip joint/socket) fracture.

Number of residents sampled:34Number of residents cited:34Based on record review and interview, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 34 residents who reside in the facility.The facility's dishwasher was not reaching appropriate temperatures.Findings includeThe facility employs a high temperature dishwasher to clean and sanitize its dishware.The facility's policy, titled Warewashing, states, in part, All dishware, service ware, and utensils will be cleaned and sanitized after each use.the dining services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware.all dish machine water temperatures will be maintained in accordance with manufacture recommendations for high temperature or low temperature machines.temperature and/or sanitizer concentration logs will be completed, as appropriate.The facility's dish machine log indicates on the bottom of the form that the wash temperature is to be 150-165 degrees Fahrenheit, and the rinse temperature is to be between 180 and 194 degrees Fahrenheit. The form is filled out three times per day, as indicated by Breakfast, Lunch, Dinner. Each time/meal, temperatures for the wash, rinse and a non-regressing thermometer are all gathered.The posted dish machine log near the dishwasher for the month of July 2025 indicates the rinse temperature did not reach 180 degrees Fahrenheit 7 times from July 1, 2025 through July 17, 2025. Additionally, the non-regressing thermometer reading did not reach 160 degrees Fahrenheit on 19 occasions.On 7/17/2025 at 1:49 PM, Surveyor interviewed DM C (Dietary Manager) who indicated that the non-regressing thermometer reading is supposed to reach at least 160 degrees Fahrenheit. DM C stated that she has not been notified of any temperatures that did not reach 180 degrees Fahrenheit for the rinse or 160 degrees Fahrenheit for the non-regressing thermometer. DM C stated that if staff had not reached the necessary temperature, they should have run the dishwasher again and if repeated attempts did not reach the necessary temperatures, she should have been notified.

Number of residents sampled:34Number of residents cited:34Based on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect the census of 34 residents. The facility has not established a line list that reflects resident's symptoms, lab results, symptom onset date, and the type of infection a resident has. Evidenced by: The facility's policy titled Infection Surveillance dated 3/8/23 states in part .1. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee, and public health authorities when required. The facility's policy titled Infection Prevention and Control Program dated 7/23/24 states in part .3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and all other individuals providing services under a contractual arrangement based upon a facility assessment and accepted standards.c. The RNs (Registered Nurses) and LPNs (licensed Practical Nurses) participate in surveillance through assessments of residents and reporting changes in condition to the residents' physicians and management staff per protocol for notification in changes and the in- house reporting of communicable diseases and infections. On 7/16/25, Surveyor reviewed the facility's infection prevention and control program for the months of April, May, and June. Surveyor noted that the documentation provided did not contain a line list that monitors all residents that have signs and/or symptoms of an actual or potential infection. The facility provided Surveyor with an Infection Control Log that includes the resident's name, the antibiotic ordered and start date and end date. This log does not include residents' symptoms, lab results, imaging results, or whether or not the resident met criteria for an antibiotic. On 7/17/25 at 10:07 AM, Surveyor interviewed IP F (Infection Preventionist) and DON B (Director of Nursing). Surveyor asked IP F if they had a line list that monitors residents that show signs/ symptoms of an actual or potential infection or illness, IP F stated that they do not have one specific list but has many. IP F stated that there is documentation in the facility's EHR (Electronic Health Record) that is completed by the nurses. Surveyor asked IP F how they are tracking and trending residents' symptoms, IP F stated that he can pull it from all the of the lists and the information in the EHR. On 7/21/25 at 10:01 AM, Surveyor interviewed DON B. Surveyor asked DON B if she would expect the Infection Preventionist to be tracking signs and symptoms of actual or potential infections on the line list, DON B stated yes. It is important to note that no additional information was provided to Surveyor regarding resident surveillance.

Number of residents sampled:1Number of residents cited:1Based on interview and record review, the facility did not follow through with the appropriate steps of the Preadmission Screening and Resident Review (PASRR) process for 1 of 1 resident (R8) reviewed.The facility does not provide R8 with specialized services per PASAAR Level 2 recommendations.Evidenced by:Per the facility, they do not have a PASRR Policy and Procedure.According to Wisconsin Department of Health Services at https://www.dhs.wisconsin.gov>pasrr, states, in part: . Preadmission Screening and Resident Review (PASRR) is a federal requirement established to identify individuals with mental illness and/or intellectual developmental disability to ensure appropriate placement in the community or a nursing facility.In brief, PASRR requires all applicants to Medicaid-certified nursing facilities be assessed to determine whether they might have an intellectual disability or mental illness. This is called a Level I screen. The purpose of a Level I screen is to identify individuals whose total needs require that they receive additional services for their intellectual disabilities or serious mental illness. Individuals who test positive at Level I are then evaluated in depth to confirm the determination of an intellectual disability or mental illness for PASRR purposes. This is a Level II screen. This assessment produces a set of recommendations for necessary services that are meant to inform the individual's plan of care.Purposes of PASRREvaluate individuals seeking admission to nursing facilities and current nursing facility residents to determine if they have a serious mental illness or an intellectual disability.Identify the individual's strengths and needs.Determine if the individual needs specialized psychiatric rehabilitation services to address his/her mental illness issues or specialized services to address his/her mental illness or intellectual disability issues.Determine if the individual needs placement in a nursing facility versus placement in an inpatient psychiatric hospital, institution for mental diseases, intermediate care facility for individuals with intellectual disabilities, or a community setting (example: group home).Notify the client or the client's legal representative and other appropriate parties of the results of the evaluations and the determinations.R8 admitted to the facility on [DATE] and has diagnoses that include severe intellectual disabilities (a significant cognitive impairment and adaptive behavior limitations, impacting daily life and requiring substantial support).R8's Care Plan dated 10/12/22, states, in part: . Focus: R8 is in need of specialized services due to diagnosis of severe intellectual disability and cerebral palsy. Date Initiated: 10/12/2022.Goal: R8 will maintain or improve her current level of functioning. Date Initiated: 10/12/2022. Revision on: 10/06/2025. Target DATE: 10/06/2025.R8 will be encouraged to make self-decisions as able. Date Initiated: 10/12/2022. Revision on: 7/09/2025. Target Date: 10/06/2025.Interventions/Tasks:Physical therapy, occupational therapy, socialization and Leisure. R8 enjoys group activities and coloring. Date Initiated: 10/12/2022.R8's PASRR Level 1 Screen was completed on 9/27/22 and was indicative of a PASRR Level II.R8's PASRR Level II dated 10/05/22, states, in part: . No- support for the diagnosis of a severe medical condition was not found OR documentation was not found that indicates that the person's level of functioning is so severely impaired by his/her medical condition that he/she could not be expected to actively participate or benefit from specialized services.Yes, this person is appropriate for a placement in a nursing facility.This person has both an intellectual developmental disability and a serious mental illness.This person needs specialized services to address his/her developmental disability needs.On 7/21/25, at 11:45 AM, Surveyor interviewed SSD D (Social Services Director) and asked if R8 requires specialized services for her intellectual disability and SSD D indicated there was confusion with the PASRR Level II as the facility received on stating R8 needed specialized services and another PASRR Level II stating she did not require specialized services both dated 10/05/22. SSD D indicated the facility was informed it was up to them as to provide the specialized services or not. Surveyor asked if SSD D could provide documentation of that. SSD D indicated it was through emails and faxes, and she would look. No documentation was provided to Surveyor. Surveyor asked SSD D how the facility interpreted the Level II. SSD S indicated the facility care planned R8 as needing specialized services. Surveyor asked SSD D what specialized services are being provided to R8. SSD D indicated the facility was using therapy at one time and activities. At one point the facility could use PT/OT and then at one point the facility could use activities. Surveyor asked if those are considered specialized services and if all residents can receive those and SSD D indicated yes all residents can receive those services. Surveyor asked at this time what services are being provided to R8 and SSD D indicated she doesn't think she has any services in place right now. SSD D indicated as far as follow up to renew the services there were none. Surveyor asked SSD D if R8 should have services provided and SSD D indicated she goes back and forth with this question. SSD D indicated R8 works with the activity director with 1:1s and sorting items. SSD D asked AD E (Activity Director) to come into her office and allow him to explain what R8 works on with him. On 7/21/25, at 11:49 AM, Surveyor interviewed AD E and asked what he works on with R8. AD E indicated he does 1:1 with R8 and R8 benefits from tasks like sorting based on color or measure activities, sorting Jenga blocks, greeting cards and exercise class. AD E indicated R8 also goes to music activities and benefits from small group. AD E indicates he works with R8 two to three times a week for 45 minutes to an hour each time. Surveyor asked if he tracks these times. AD E indicates he puts them in PCC but not specific to what the task is. On 7/21/25, at 1:35PM, Surveyor interviewed DON B (Director of Nursing) and asked if the facility recognizes R8 as requiring specialized services and DON B indicated yes. Surveyor asked if activities and therapy are considered specialized services and DON B indicated no. R8 is not being provided with specialized services per PASAAR Level 2 recommendations.

Based on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 1 of 1 resident reviewed for grievances (R13). R13 expressed concerns regarding asking for assistance with ADLs (Activities of Daily Living) that was not completely investigated by the facility. Evidenced by: The facility's policy titled Grievance Policy dated 7/2022 states in part .When a Complaint/ Grievance Report is initiated: .The original form will then be forwarded to the department head for which the Grievance pertains to (i.e. Dietary Manager for food and dining related issues, DON (Director of Nursing) for any nursing or clinical related issues.). The Department Head that is assigned the concern form is responsible for investigating the issue within 72 hours of being assigned the grievance. The Grievance Officer will ensure: during the investigation, the Grievance Officer will prevent any potential or further violation of resident rights.The Grievance Officer will ensure that: .written grievance resolution decisions include the date when the original concern was received, a summary statement of the concern, steps taken to investigate, a summary of findings or conclusions regarding the concern, whether the concern was confirmed or not, any corrective action taken and the date the decision was issued. R13 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (left sided weakness/ paralysis following a stroke), pain, major depressive disorder, and hypertension (high blood pressure). R13's most recent MDS (Minimum Data Set) dated 5/30/25, states that R13 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R13 is cognitively intact. The MDS also states that R13 requires partial/ moderate assistance with lower body dressing and personal hygiene. R13's care plan dated 11/13/24 states in part .Focus: ADL self- care deficit evidenced by: CVA (Cerebral Vascular Accident (stroke)). Goal: Will maintain existing ADL self performance [sic]. Interventions/ Tasks: .Personal Hygiene: Independent with set up of items (revised on 5/20/25) . It is important to note that R13's care plan does not address the amount of assistance that they require with dressing. On 5/28/25 a grievance form was filled out for R13. The form states in part:.Detail of complaint/ grievance: Resident upset d/t (due to) not getting enough help with ADLs. Resident is independent with ADLs and often refuses to dress himself.Person completing this form: NHA A. Person investigating complaint/ Grievance: NHA A/ SSD (Social Services Director). Grievance official follow-up: Resident interviewed by myself and SSD. Resident continues to be upset when independence is referenced. States can't do things all on own, then begins to perseverate on therapy. Writer redirects without success, SSD redirects. No resolution as resident continues to believe he should not be independent and d/c (discharged ) from therapy.Date resolved: 5/28/25. Resident is not satisfied but needs to move toward independence with ADLs to return to community. On 7/15/25 at 10:20 AM, Surveyor interviewed R13. R13 reported to Surveyor that they do not get the help they need with dressing, and that staff tell them they can do it themself. On 7/17/25 at 8:26 AM, Surveyor interviewed PTA M (Physical Therapy Assistant) and COTA N (Certified Occupational Therapy Assistant). Surveyor asked PTA M and COTA N if R13 was being seen by therapy, PTA M stated no. Surveyor asked what R13's ADL abilities are, PTA M stated that he was independent in his room, but was asking for some help and that R13 had been transferring independently in the bathroom but was still asking for help. Surveyor asked PTA M and COTA N if R13 is independent with all ADLs, COTA N stated that R13 reported that he could do it, and that he said he was able to put his shirt and pants on by himself. Surveyor asked COTA if there was any documentation of R13's abilities, COTA N stated that there weren't any notes. On 7/17/25 at 2:16 PM, Surveyor interviewed NHA A. NHA reported that he was the Grievance Official. Surveyor asked NHA A what the process is for investigating a grievance, NHA reported that he receives the grievance, the grievance form gets filled out, they assign someone to investigate the concern, he reviews the investigation, follows- up with the resident/ resident representative. Surveyor asked NHA to explain the investigation completed in regard to R13's grievance, NHA A stated that R13 didn't want to be discharged from therapy, wanted assistance with ADLs, and stated that he was not independent. Surveyor asked NHA A if he interviewed CNAs (Certified Nursing Assistants) regarding R13's need for assistance, NHA A stated yes. Surveyor asked NHA A if the interviews were documented, NHA A stated no. Surveyor asked NHA A if therapy was consulted and the recommendations were reviewed, NHA A stated that therapy reported that R13 is independent. Surveyor asked NHA A if R13 was re-evaluated by therapy after this incident, NHA A stated yes. Surveyor requested therapy documentation.OT (Occupational Therapy) Discharge summary dated [DATE] states in part: .Dressing: Upper body dressing = Supervision or touching assistance. Lower body dressing = Partial/ moderate assistance. Putting on/ taking off footwear = Partial/ moderate assistance.Therapy Screen/ Communication form dated 3/27/25 states in part: .Pt. declined: Stated he can do everything on his own. On 7/17/25 at 3:42 PM, Surveyor interviewed NHA A. Surveyor asked NHA A if they had reviewed the OT documentation, NHA A stated yes. Surveyor asked NHA A if therapy was unable to complete an assessment, should R13's abilities regarding his ADLs be referred to his previous level, NHA A stated yes. The facility failed to investigate R13's concerns about needing help with ADLs, indicating that he should complete them independently.

Number of residents sampled: 12Number of residents cited:1Based on interview and record review the facility did not develop a comprehensive care plan or review and revise the comprehensive care plan for 1 of 12 sampled residents (R13).R13's care plan did not address the type of assistance required for dressing.Evidenced by:The facility's policy titled Comprehensive Care Plan revised on 9/23/22 states in part .1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care.3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well- being.R13 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (left sided weakness/ paralysis following a stroke), pain, major depressive disorder, and hypertension (high blood pressure). R13's most recent MDS (Minimum Data Set) dated 5/30/25, states that R13 has a BIMS (Brief Interview of Mental Status) of 15 out of 15, indicating that R13 is cognitively intact. The MDS also states that R13 requires partial/ moderate assistance with lower body dressing and personal hygiene.R13's care plan dated 11/13/24 states in part .Focus: ADL(Activities of Daily Living) self- care deficit evidenced by: CVA (Cerebral Vascular Accident (stroke)). Goal: Will maintain existing ADL self performance [sic]. Interventions/ Tasks: .Personal Hygiene: Independent with set up of items (revised on 5/20/25) .It is important to note that R13's care plan does not address the amount or type of assistance that they require with dressing.OT (Occupational Therapy) Discharge summary dated [DATE] states in part: .Dressing: Upper body dressing = Supervision or touching assistance. Lower body dressing = Partial/ moderate assistance. Putting on/ taking off footwear = Partial/ moderate assistance.On 7/15/25 at 10:20 AM, Surveyor interviewed R13. R13 reported that he is not getting the help that he needs from facility staff.On 7/17/25 at 9:34 AM, Surveyor interviewed CNA O (Certified Nursing Assistant). Surveyor asked CNA O how much assistance R13 requires with ADLs, CNA O stated that R13 is supposed to be independent, but R13 needs assistance with putting on his socks and pants but can put his shirt on by himself most of the time. Surveyor asked CNA O what R13's care plan says about the amount of assistance he requires, CNA O stated that it says he's independent. Surveyor and CNA O reviewed R13's care plan. After reviewing the care plan, Surveyor asked CNA O if the care plan states that R13 is independent with dressing, CNA O stated no. Surveyor asked CNA O if the care plan addresses R13's ability to dress, CNA O stated no.On 7/17/25 at 2:50 PM, Surveyor interviewed R13. Surveyor asked R13 what ADLs he was able to complete on his own once discharged from therapy, R13 stated that he was able to walk to therapy and take himself to the bathroom. Surveyor asked if he was able to dress himself, R13 stated no and that he needs assistance.On 7/21/24 at 9:54 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the process is for putting therapy recommendations onto the care plan, DON B stated that therapy gives the recommendations to the nurses and the nurses update the care plan. Surveyor asked DON B if she was aware that OT's recommendation for R13's dressing was partial/ moderate assist, DON B stated no. Surveyor asked DON B if she would expect that to be on R13's care plan, DON B stated yes.

Number of residents sampled:2Number of residents cited:1Based on interview and record review the facility failed to maintain acceptable parameters of nutritional status and consult with the residents Physician on this for 1 of 2 residents (R4) reviewed for nutrition of a total sample of 13 residents. R4 had a severe weight loss of 11.29% in 6 months. The facility did not put interventions into place to prevent weight loss or update the physician during the 6-month period. Evidenced by:The facility policy entitled Weight Monitoring, dated 12/21/22, states, in part: . Policy: The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents.Procedure:Weight Assessment.7. The dietician will review the monthly weights to follow individual weight trends over time. Weight trends will be evaluated by the interdisciplinary team whether or not the criteria for significant weight change have been met.8. The threshold for significant weight change will be based on the following criteria [where percentage of body weight change= (usual weight-actual weight) / (usual weight) x 100]: a. 1 month- 5% weight change is significant; greater than 5% is severe. b. 3 months- 7.5% weight change is significant; greater than 7.5% is severe. c. 6 months- 10% weight change is significant; greater than 10% is severe.10. The nursing staff will notify the individual or responsible party, physician and RDN (registered dietician) or designee of any individual with an unintended significant weight change. Care Planning: .2. Individualized care plans shall address to the extent possible: a. The identified causes of weight change; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment.Interventions:1. Interventions for undesirable weight change shall be based on careful considerations of the following: .b. Nutrition and hydration needs of the resident. R4 admitted to the facility on [DATE] and has diagnoses that include Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (a condition where the body doesn't produce enough insulin or can't properly use the insulin it makes, leading to high blood sugar levels causing kidney damage), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and mild intellectual disabilities (deficits in intellectual functions pertaining to abstract/theoretical thinking).R4's Care Plan, dated 4/11/23, states, in part: . Focus: At risk for nutritional status change related to Type DM (diabetes mellitus), CKD (chronic kidney disease), hyperkalemia, GERD, history of weight loss, diuretic use. Date Initiated: 4/11/23Goal: Will maintain weight as evidenced by no significant weight changes (>/= 5% in 30 days, >/= 7.5% in 90 days, or >/= 10% in 180 days).Date Initiated: 4/11/23. Revision on: 6/06/2025. Target Date: 9/02/2025.Interventions/Tasks: .-Eating- assist of 1 Date Initiated: 6/04/2025. Revision on: 6/04/2025.-Provide diet as ordered: Renal diet, L2/Mech Alt texture (level 2), Regular/Thin consistency, Low potassium. Date initiated: 4/11/2023. Revision on: 6/04/2025. R4's weights per facility record are as follows:*7/15/25- 154 (7# (pound) loss from previous month, 19.6# loss 6 months, 11.29% loss in 6 months)*6/17/25- 161 (5# loss from previous month)*5/13/25- 156*4/01/25- 155 (17# loss from previous month)*3/01/25- 172*2/14/25- 169 (4.6# loss from previous month)*1/01/25- 173.6 R4's Physician's Orders dated 7/17/25 include:-Renal diet L2/Mech Alt texture, Regular/Thin consistency, for ground meat Low Potassium Diet, at least 64 ounces of fluid per day Diet type: Renal for renal. Order Date: 5/20/2025.-Weight- (weekly) (Obtain re-weight if change of 5 lbs. since last weight) one time a day every Tuesday. Order Date: 4/29/2025. R4's Progress Note dated 4/08/25, at 11:21 AM, states, in part: . Writer reviewed weights. Will send recommendation. R4's Progress Note dated 4/29/25 at 10:03 AM, states, in part: . Average meal intake x 7 days = 75%-100% with occasional meals in 0-75% range and 2 meals refused per charting. Will send recommendations.R4's Progress Note dated 5/28/25, 2:47PM, states, in part: . Note Text: WEIGHT WARNINGValue: 159.0.-7.5% change [7.6%, 13.0]Weight has remained stable the past month with minor fluctuation. Meal intakes average >75% with occasional intakes <50% noted. Due to stabilization of weight recommend to continue current nutrition POC. R4's Progress Notes dated 7/09/25 2:04PM, states, in part: Type: Weight NoteNote Text: WEIGHT WARNINGValue: 155.0.MDS (Material Data Set): -10.0% change over 180 days [11.9%,21.0]Wt. (weight) Hx. (history)- 1 month ago: 157#, 3 months ago: 155#, 6 months ago: 176# BMI (body mass index) 25; 6# weight loss noted in the past month. Meal intakes average >51% with occasional intakes <51% noted and refusals occasionally.Due to stabilization of weight will continue current nutrition POC (Plan of Care) .On 7/17/25 at 10:15 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor reviewed with DON B R4's weights of 154# on 7/15/25, 161# on 6/17/25, 156# on 5/13/25, 155# on 4/1/25, 172# on 3/1/25, 169# on 2/14/25 and 173.6 on 1/1/25. Surveyor asked DON B if -11.29% loss in 6 months was a significant weight loss and DON B indicated yes. Surveyor asked DON B what the process is for weight monitoring. DON B indicated 5% or more loss in one month, 7.5% loss in 3 months, or 10% or more loss in 6 months. DON B indicated she tracks all resident weights every Monday she goes through the (computer system) alerts in red on residents. The dietician sends DON B a report every two weeks also on weight alerts. If a reweight is necessary we do a reweight. We assess the resident and update physician and POA (power of attorney). DON B indicated if any interventions are put into place we update the POA. Surveyor asked DON B if interventions were put into place during the last 6 months with weight loss. DON B reviewed R4's physicians orders and indicated no. DON B indicated she would go by the dietician's recommendations. If dietician recommended a supplement DON B would get an order. DON B indicated if the dietician did not make recommendations with weight loss DON B would still update the physician on the weights and see if physician wants changes. Surveyor asked DON B if physician was updated with weight losses since January. DON B indicated she does not recall off hand but did fax physician on Monday. DON B indicated the physician should have been updated within the last 6 months with weight changes and DON B would expect interventions to be put into place for weight loss.On 7/17/25 at 10:50 AM, Surveyor interviewed RD G (Registered Dietician) and reviewed R4's weights of 173.6 on 1/1/25 and 154 on 7/15/25 and asked if -11.29% loss is considered a severe weight loss in 6 months and RD G indicated yes. RD G indicated she took over the building a month and a half ago and she had not made any recommendations as R4's weights were stable for the past three months, since 4/1/25. RD G indicated if she had looked at a weight trigger January or February and seeing that trend then maybe she would have made a recommendation. RD G indicated recommendations are made by looking at history of weight loss, intakes, and is a reweigh required. RD G indicated the whole picture of the resident gets reviewed.R4 experienced a severe weight loss of 11.29% in 6 months. The facility did not put interventions into place to prevent weight loss or update the physician during the 6-month period.

Number of residents sampled:7Number of residents cited:3Based on interview and record review, the facility does not follow a nationally recognized standard of practice for infection control or monitoring antibiotic use, and they do not have protocols in place to obtain cultures and other reports to ensure residents are receiving the correct antibiotic for 2 of 7 residents (R30 and R25) reviewed for infections. R30 was started on an antibiotic and had no documented signs of an infection. R25 received orders for a UA (Urinalysis) without meeting criteria and was subsequently placed on an antibiotic. Evidenced by: The facility's policy titled Antibiotic Stewardship Program revised on 11/18/22 states in part .4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. Nursing staff shall assess/ gather data on residents who are suspected to have an infection and notify the physician. Documentation shall include the assessment or data gathered and the physician notification. ii. Laboratory testing shall be in accordance with current standards of practice. v. Prescriptions for antibiotics shall specify the dose, duration, and indication for use.b. Monitoring antibiotic use: .ii. Antibiotic orders obtained on admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness.iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. Example 1R30 was admitted to the facility on [DATE] with diagnoses that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), diabetes insipidus ( a disease that causes the body to make large amounts of urine and can lead to extreme thirst- occurs when fluid levels in the body are thrown out of balance), and general anxiety disorder. The facility form titled Criteria for Infection Report Form- Urinary Tract Infections (UTIS) dated 6/28/25 lists the following criteria: Resident exhibits: Fever (>100 degrees F (Fahrenheit) or 2.4 degrees above baseline or 2 or more instances in the past 12 hrs (hours) AND 2 or more symptoms not related to urinary tract infection (i.e. respiratory s/s (signs/ symptoms, GI (Gastro- intestinal), skin symptoms, etc.). If YES- Urine culture is NOT indicated, if NO- proceed to urinary symptom check. Urinary Symptom Check: Fever (>100 degrees F (Fahrenheit) or 2.4 degrees above baseline or 2 or more instances in the past 12 hrs (hours) AND 1 or more: Dysuria (pain or burning during urination), Urgency, Frequency, Suprapubic pain (lower abdomen pain), Gross Hematuria (blood in urine), Flank pain, Urinary Incontinence, Shaking Chills. If YES- Meets Criteria to order urine culture, if NO- Does not meet criteria. Results of Urine Culture: >105 CFU/ml (Colony forming units per milliliter) (positive) or pending urine culture AND dysuria. If YES- Meets criteria for antibiotic per physician order, if NO- Does not meet criteria. Or if resident experiences 2 or more of the following: Fever (>100 degrees F (Fahrenheit) or 2.4 degrees above baseline or 2 or more instances in the past 12 hrs (hours), Urgency (new or worsening), Suprapubic pain, Gross hematuria, flank pain, urinary incontinence, shaking/ Chills. If YES- Meets criteria for antibiotic per physician criteria, if NO- does not meet criteria. R30's form does not have any criteria marked, but states Klebsiella in the comments. R30's urine culture results received on 6/28/25 states: Culture- Urine Colony count = >100,000 cfu/ml Klebsiella oxytoca. It is important to note, that according to the facility's form, R30 does not meet the criteria for an antibiotic. On 6/30/25, R30 was started on Nitrofurantoin Macrocrystal Capsule 100mg one time a day for 7 days. On 7/17/25 at 10:07 AM, Surveyor interviewed IP F (Infection Preventionist) and DON B (Director of Nursing). Surveyor asked IP F what R30's symptoms were and if R30 met criteria for a UA (Urinalysis) and an antibiotic, IP F stated that R30 did not have any symptoms, and that the UA was obtained at a doctor's appointment. Surveyor asked IP F if R30 met criteria for an antibiotic, IP F stated that he thought R30 met criteria by testing positive for Klebsiella. Surveyor asked IP F and DON B if the provider was updated regarding R30 being asymptomatic and not meeting the colony count for an antibiotic, DON B stated no, and the provider should have been updated. Example 2: R25 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia, major depressive disorder, and weakness. The facility form titled Criteria for Infection Report Form- Urinary Tract Infections (UTIS) dated 4/19/25/25 lists the following criteria: Resident exhibits: Fever (>100 degrees F (Fahrenheit) or 2.4 degrees above baseline or 2 or more instances in the past 12 hrs (hours) AND 2 or more symptoms not related to urinary tract infection (i.e. respiratory s/s (signs/ symptoms, GI (Gastro- intestinal), skin symptoms, etc.). If YES- Urine culture is NOT indicated, if NO- proceed to urinary symptom check. Urinary Symptom Check: Fever (>100 degrees F (Fahrenheit) or 2.4 degrees above baseline or 2 or more instances in the past 12 hrs (hours) AND 1 or more: Dysuria (pain or burning during urination), Urgency, Frequency, Suprapubic pain (lower abdomen pain), Gross Hematuria (blood in urine), Flank pain, Urinary Incontinence, Shaking Chills. If YES- Meets Criteria to order urine culture, if NO- Does not meet criteria. Results of Urine Culture: >105 CFU/ml (Colony forming units per milliliter) (positive) or pending urine culture AND dysuria. If YES- Meets criteria for antibiotic per physician order, if NO- Does not meet criteria. Or if resident experiences 2 or more of the following: Fever (>100 degrees F (Fahrenheit) or 2.4 degrees above baseline or 2 or more instances in the past 12 hrs (hours), Urgency (new or worsening), Suprapubic pain, Gross hematuria, flank pain, urinary incontinence, shaking/ Chills. If YES- Meets criteria for antibiotic per physician criteria, if NO- does not meet criteria. R25's form does not have any criteria marked, but states + E. Coli report and delirium, incontinence. in the comments. R25's urine culture results received on 4/21/25 states: Culture- Urine Mixed flora also present. Colony Count => 100,000 cfu/ ml Escherichia coli. It is important to note, that according to the facility's form, R25 does not meet the criteria for an antibiotic. On 4/19/25, R25 was started on Bactrim DS 800-160mg (milligrams) 1 tablet two times a day for UTI for 3 days. R25's antibiotic was changed on 4/21/25 to Nitrofurantoin Macrocrystal Capsule 100mg two times a day for 7 days. On 7/17/25 at 10:07 AM, Surveyor interviewed IP F and DON B. Surveyor asked IP F if R25 had any UTI symptoms prior to a UA being obtained, IP F stated that family was concerned that R25 was confused, and resident was experiencing incontinence. Surveyor asked what interventions were tried prior to obtaining a UA, DON B stated that there is nothing documented as far as pushing fluids. Surveyor asked IP F if R25 met criteria for an antibiotic, IP F stated no. Surveyor asked IP F if R25's physician was updated about not meeting criteria, IP F stated no. It is important to note that R25's most recent MDS (Minimum Data Set) dated 4/22/25, Section H stated that R25 is frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). On 07/21/2025 10:01, Surveyor interviewed DON B. Surveyor asked DON B if she would expect IP F to contact the provider if a resident doesn't meet criteria for an antibiotic, DON B stated yes.

Based on observation, record review, and resident and staff interviews, the facility did not develop and implement a comprehensive resident-centered care plan for 1 of 5 sampled residents reviewed (R2). R2 has a history of making false allegations. This is not on R2's comprehensive care plan. Evidenced by: The facility's Comprehensive Care Plan policy, dated 9/23/22, includes, in part, the following: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. R2 was admitted to the facility on [DATE]. R2's diagnoses includes stroke, vascular dementia, and anxiety. R2's most recent Minimum Data Set (MDS), dated [DATE], includes in part, the following: R2 has severe cognitive impairment and does not have any behaviors. The facility's self-report, dated 7/2/24, includes, in part the following: Brief Summary of Incident: LPN F (Licensed Practical Nurse) called this writer and reported that HHS (Health and Human Services) had called her and reported that they were made aware of R2 reporting that [NAME] (sic) Nurse left bruises on her. RN C (Registered Nurse) is our only Male Nurse. R2 has a BIMS (Brief Interview of Mental Status) of 0. A complete head to toe assessment of the resident was performed this evening. The RN was removed from the schedule for tomorrow and we will notify law enforcement on 7/3 and conduct a full investigation. Outcome: . The Sheriff's Department reported interviewing FM G (Family Member) who is R2's guardian and reports that the guardian had no suspicions or concerns about (R2's) safety and well-being. Also (FM G) reports that his mother (R2) has a history of making false abuse allegations. On 9/4/24 at 2:10 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if she was aware of R2's history of making false allegations. DON B stated R2 has been making false allegations since she was admitted . Surveyor asked DON B if R2 is making false allegations has the facility care planned this; DON B stated no, this was not on R2's comprehensive care plan but should be.

Based on interview and record review, the facility did not immediately consult with the resident's physician when there is a need to alter treatment for 1 out of 3 residents (R) reviewed for physician notification (R1). R1 had a change of condition and the facility failed to update the physician. R1 had an oxygen saturation level outside of parameters on several occasions and the physician was not updated. Facility staff also increased R1's oxygen without updating the physician or receiving orders to increase oxygen. This is evidenced by: Facility policy, titled, Change in Condition of the Resident, last reviewed 9/20/22, states in part . Policy: A facility should immediately inform the resident; consult with the resident's physician; and notify consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). 1. Assess the resident's need for immediate care / medical attention. Provide emergency care as needed. 2. Assess/evaluate the resident. 3. Notify resident's physician - Use INTERACT Change in Condition: When to report to the MD/NP/PA (Medical Doctor, Nurse Practitioner, Physician Assistant) as a guideline. a. Immediate notification: Immediate notification for any symptom, sign or apparent discomfort that is: i. Acute or sudden onset, and: ii. A marked change (i.e., more severe) in relation to usual symptoms and signs, or: iii. Unrelieved by measures already prescribed requires a phone call to the provider. 5. Monitor resident's condition frequently until stable or transported to a higher level of care, if needed. Facility document titled, Standing Orders Facility Protocol, states in part . Oxygen therapy 1-3L/min (liters a minute) per nasal canula to keep O2 sat (saturation) above 90% (percent) for SB (shortness of breath), dyspnea, or chest pain. Interact Version 4.5 Tool for Change in Condition: When to report to the MD/NP/PA, states in part . Immediate Notification: Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and: A Marked Change (i.e., more severe) in relation to usual symptoms and signs, or Unrelieved by measures already prescribed. Vital Signs: Report Immediately: Oxygen saturation <90% (less than 90 percent). R1 was admitted to the facility on [DATE], with diagnoses, including, but not limited to: malignant neoplasm of unspecified part of bronchus or lung (lung cancer), secondary malignant neoplasm of bone (bone cancer), acute and chronic respiratory failure with hypoxia, pulmonary hypertension (high blood pressure in the lungs arteries), and nonrheumatic mitral insufficiency (mitral valve does not close properly). R1's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/7/24 indicates R1 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R1's hospital discharge summary, dated 5/1/24, states in part . Oxygen-outpatient/home use therapy Oxygen for portability Equip (equipment): Concentrator and Cylinders w/ (with) contents and Regulators. O2 Use: 3 LPM (liters per minute) at rest nasal canula and 3 LPM w/ activity nasal canula. Lifetime need. Recommendations: Continue supplemental oxygen: 3L (liters) at rest, 3L with activity. Physician progress note from 5/9/24, states in part . Plan: .2. Lung cancer with Mets (metastasis/spread) to bone and brain. Add in his brother [sic]. They are hopeful that with some rehab here at the nursing home that it [sic] can get stronger and return to chemotherapy treatments. He is [sic] albuterol neb as needed. Oxygen 3 liters/minute. He has Decadron 0.5 daily. Bactrim DS (antibiotic) once daily as prophylaxis for this immunocompromise state . R1's physician orders for May 2024, include, in part: Oxygen at 3l/min (liters per minute) via nasal cannula. Start Date: 5/1/24. R1's Medication Administration Record (MAR) from May 2024, includes, in part: Check O2 sat every shift. R1's documented O2 saturations, state in part . 5/02/24, AM (day) shift, 98% at 4L/min 5/03/24, NOC (night) shift, 89% at 4L/min 5/04/24, NOC shift, 89% at 4L/min 5/07/24, AM (day) shift, 85% at 4L/min 5/07/24, NOC shift, 89% at 4L/min 5/08/24, AM shift, 87% at 3L/min 5/08/24, PM (evening) shift, 88% at 3L/min 5/08/24, NOC shift, 87% at 3L/min 5/09/24, AM shift, 85% at 3L/min. Physician in on rounds and assessed R1. 5/09/24, NOC shift, 89% at 3L/min 5/10/24, AM shift 94% at 4L/min. 5/10/24, NOC shift, 88% at 3L/min 5/11/24, AM shift, 84% at 3L/min 5/11/24, PM shift, 80 % at 3L/min 5/11/24, NOC shift, 86% at 3L/min 5/12/24, AM shift, 84% at 3L/min. MD notified of status. 5/12/24, PM shift, 89% at 4L/min 5/12/24, NOC shift, 67% at 4L/min 5/13/24, AM shift, 69% at 4L/min. R1 sent to hospital. Note: Facility staff did not obtain orders to increase R1's oxygen above the ordered 3L/min. R1's oxygen was increased above 3 on several occasions as noted above. Note: Facility staff did not update the physician when R1's oxygen saturation levels would fall below 90% following the INTERACT guidelines. On 9/4/24 at 1:30 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what standard of practice the facility uses. DON B stated, interact or AMDA (American Medical Directors Association) guidelines. Surveyor asked DON B if staff should increase oxygen on a resident without a physician's order. DON B stated, staff should not have gone above the ordered 3L/min without an MD (medical doctor) order. Surveyor asked DON B if the physician should have been notified when R1's oxygen saturation levels decreased below 90%. DON B stated, absolutely, if saturations dropped below 90%. On 9/4/24 at 1:45 PM, Surveyor interviewed RN C (Registered Nurse). Surveyor asked RN C what standard of practice the facility uses. RN C stated, Interact. Surveyor asked RN C if a residents oxygen saturation drops below 90% what should be done. RN C stated, that is not normal and would require physician notification. Surveyor asked RN C if staff should increase oxygen without physicians orders. RN C stated, no, would need an order to increase oxygen. On 9/4/24 at 2:30 PM, Surveyor interviewed RN D. Surveyor asked RN D what standard of practice the facility uses. RN D stated, Interact. Surveyor asked RN D if staff should increase oxygen without physicians orders. RN D stated, no, unless it is below what we have for standing orders but would still need to update the physician. On 9/4/24 at 2:40 PM, Surveyor interviewed ADON E (Assistant Director of Nursing). Surveyor asked ADON E about R1's care in the facility. ADON E stated, the resident's family was not accepting of his diagnoses. Surveyor asked ADON E if staff should increase a resident's oxygen without a physician's order and when a physician should be notified. ADON E stated, anything under 90% requires physician notification. Staff could increase oxygen short-term while calling the physician, but oxygen should not be turned up and left without that notification. The facility failed to update R1's physician of oxygen saturation levels below 90% and failed to update when oxygen increased above the physician's order of 3L/min.

Based on observation and interview, the facility failed to distribute food under sanitary conditions, did not utilize proper glove use and handled food without proper hand hygiene. This has the potential to affect all 35 residents who reside in the facility. This is evidenced by: The facility policy and procedures for Healthcare Services Group entitled, Infection control overview & Policy, states in part, Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination. The policy also states food should be labeled and dated with a prepared date and a use by date. On 05/06/24 at 9:30 AM, during the initial kitchen tour, Surveyor toured with Certified Dietary Manager (CDM) C and observed opened and undated containers of a gallon of chocolate milk, gallon of whole milk, jug of buttermilk ranch dressing, and bag of frozen cheese omelets. On 05/06/24 at 9:30 AM, Surveyor observed the sign on kitchen bulletin board stating in part .milk labeling 4/21/26: Document on Jug/Carton the date opened. On 05/07/24 at 7:00 AM, Surveyor observed an opened and undated gallon of whole milk and chocolate milk on fluid cart prepared for breakfast service. On 05/06/24 at 9:30 AM, Surveyor interviewed CDM C who stated expectation that food items that are opened are labeled with date opened and date of discard. On 05/07/24 at 7:00 AM, Surveyor observed Cook D standing near a 3-tier cart with a cup and cookie in hand and set them down on top of cart when Surveyor walked in. Sitting next to cup and half eaten cookie was a 1/2 a can of opened [NAME] beans with a spatula inside. A full sheet of unfrosted cake covered with saran wrap was observed on the shelf below. Cook D stated to Surveyor, You caught me. I didn't think you would be in so early. Cook D stated the can of beans will be served at lunch and the cake is for next day bible study. Surveyor continued constant surveillance of Cook D, who did not conduct hand hygiene after drinking and eating the cookie. Cook D proceeded to prepare for breakfast service. During observation Surveyor observed Cook D touch face with bare hands, rest elbow on counter and placed chin on hands, grabbed a pen from table and documented temperatures, touched outside of cereal containers, donned gloves to take a frozen egg omelet out of freezer, removed gloves and began gathering various supplies (i.e., brown sugar, serving utensils, oven mitts. plates and tray cards). No hand hygiene was observed prior to donning and doffing gloves or before, during and after completing tasks. On 05/07/24 at 8:18 AM, Surveyor continued constant surveillance of Cook D serving breakfast to all facility residents touching lips of plates and bowls without conducting hand hygiene before, during or after breakfast meal service. On 05/07/24 at 12:03 AM, Surveyor observed Cook D putting away unused food item, picking up and placing dirty dishes in 3-compartment sink, and clean prep area prior to lunch meal service. On 05/07/24 at 12:13 PM, Cook D began serving lunch to all facility residents by grabbing a stack of small dishes, pinching thumb inside each dish served. No hand hygiene was conducted prior to, during or after lunch meal service. On 05/08/24 at 9:43 AM, Surveyor interviewed Cook D regarding staff eating in kitchen and expectation of conducting hand hygiene. Cook D stated that staff are not supposed to eat in kitchen area and the expectation for hand hygiene is to be conducted any time touching something dirty, before and after gloves use, before and after eating, and before serving food. On 05/08/24 at 10:04 AM, Surveyor interviewed CDM C regarding expectation of staff eating in kitchen and conducting hand hygiene. CDM C confirmed that staff should not be eating and drinking in kitchen area and hand hygiene should be conducted after touching contaminated items, before and after glove use, before and after eating, and before serving food.

Based on interview and record review, the facility did not ensure the mandatory staffing data that had been submitted from 07/01/23-12/31/23 (Quarter 4 2023 and Quarter 1 2024) was complete, accurate, and auditable. This can affect all 35 residents residing in the facility. This is evidenced by: The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document that the facility triggered for Excessively Low Weekend Staffing and One Star Staffing Rating from 07/01/23-12/31/23 (Quarter 4 2023 and Quarter 1 2024). There were no specific dates listed. Surveyor reviewed the facility's time sheets for weekends in the months in question and found adequate staffing on all weekends. Surveyor reviewed the facility's Daily Schedule sheets for the months of October 2023 to December 2023 and did not find any weekends that had low weekend staffing concerns. Surveyor interviewed family members and residents who did not share any complaints or concerns regarding weekend staffing. On 05/07/24 at 1:04 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and [NAME] President of Success (VPS) E regarding the low weekend staffing trigger in the PBJ. NHA A indicated the issue was due to reporting errors on time cards when the facility was using agency staff to fill in required shifts. During the week this was not an issue as they had over-adequate staffing numbers. Reporting was not done correctly on weekends when agency staff were utilized. The corporation recognized this as an error across many facilities and set out to fix it at the beginning of the year. The corporation determined a disconnection in how facilities report the agency staff hours to corporate. Agency staff time cards were not being locked in the corporate SmartLink (time card system) system so the data was not being pulled into the PBJ reports when submitted. After determining the issues, corporate educated administrators on 03/18/24 regarding the proper way to submit staff information to corporate, which has fixed the problems. They have now implemented three different monitoring systems and lock time cards after being submitted to reduce the chance of error. VPS E was able to produce emails regarding the training on 03/18/24, proving that training for administration did occur. This is being cited as past noncompliance with the completed date of 03/18/24, the date of education to fix the issues in reporting.

Based on record review and interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (R21). Findings include: The facility policy entitled, Fall Prevention and Management Guidelines, last reviewed/revised on 11/09/22, lists in part . -provide interventions that address unique risk factors. -interventions will be monitored for effectiveness. -contributing factors to fall -review of investigation and determination of potential root cause of fall. The facility policy entitled, Resident Alarms, last reviewed/revised on 09/09/22, states in part, The facility shall establish and utilize a systematic approach for the safe and appropriate use of resident alarms which includes verifying alarms are working properly. R21 was admitted to facility on 08/27/21 and has diagnoses that include, Alzheimer's disease, unspecified dementia, difficult in walking and muscle weakness. R21's most recent Minimum Data Set (MDS) Assessment, which was a significant change in condition, dated 02/12/24, and indicates R21 has both short term and long-term memory problems, severely impaired - rarely/never made decisions and Bed/chair alarms are used daily. Facility fall risk assessment completed on 02/07/24 indicates R21 is at moderate risk for falls. R21's physician order with start date of 09/01/22 states to change battery for all alarms on the 1st of every month. R21's physician order with start date of 07/06/23 states to check for proper placement and functioning of alarms every shift. R21's care plan initiated on 09/07/21 and last updated on 02/01/24 indicates R21 is at risk for falls due to history of falls, impaired balance/poor coordination, syncope/vertigo, and unsteady gait. R21's current fall interventions include: -Ensure antiroll back brakes initiated on 12/14/21 are functioning properly. -Bed and chair alarms at all times initiated on 01/23/22. -Ensure Dycem is in wheelchair prior to assisting into wheelchair initiated on 10/27/23. -Provide assistance to transfer and ambulate initiated on 09/07/21. -Reinforce need to call for assistance initiated on 09/07/21. -Gripper socks and/or shoes at all times revised on 08/10/23. Noted care planned prior to have gripper socks at all times initiated on 09/29/22. On 05/07/24 at 11:18 AM, Surveyor reviewed R21's fall investigations and noted: R21 had an unwitnessed fall on 12/29/23 at 5:30 PM, wherein R21 was found lying on the bathroom floor, bowel movement in toilet, wheelchair alarm not sounding, and brakes not locked. -Interventions put into place at time of fall were changing the batteries in alarm and re-situated Dycem as old was crinkled up on top of alarm. -Treatment record on 12/29/23 indicated that alarms were checked every shift for proper placement and functioning of alarms by nursing staff and no indication of not functioning properly was noted. -No investigation/intervention was completed as to why the alarm not functioning. -No intervention/intervention was completed as to why the wheelchair brakes were not functioning. R21 had an unwitnessed fall on 01/18/24 at 3:20 AM, wherein R21 was found on floor next to bed and bed alarm was unplugged. -Interventions put into place were to remind staff to put gripper socks on and plug in bed alarm. -Treatment record on 01/18/24 indicated that alarms were checked every shift for proper placement and functioning of alarms by nursing staff and no indication of not functioning properly was noted. -No intervention/investigation was completed as to why the alarm was unplugged. On 05/09/24 at 8:56 AM, Surveyor interviewed Director of Nursing (DON) B regarding 12/29/23 and 01/18/24 falls. DON B stated an investigation was not conducted as to why alarms or anti-lock brakes were not working or became unplugged. The facility did not discuss concerns during Interdisciplinary team meetings or during Quality Assurance meetings. On 05/09/24 at 9:46 AM, Surveyor interviewed DON B regarding expectation from staff when a device is found not working. DON B stated her expectation would be for staff to investigate in attempt to determine reason and either fix or replace device.

Based on observation, interview and record review, the facility did not ensure assessments for bowel continence and interventions to maintain current bowel continence were implemented to maintain bowel function for 1 of 1 resident reviewed with a bowel incontinence (R25). This is evidenced by: R25 was admitted to the facility on [DATE] and has diagnoses that include neurogenic bladder, acute pyelonephritis, diabetes mellitus type 2 and mild intellectual disability. R25's Minimum Data Set (MDS), dated [DATE], indicates that R25 has a Brief Interview for Mental Status (BIMS) score of 99 (unable to complete interview), an indwelling Foley catheter, bowel continence of not rated, uses a Hoyer lift for transfers and is dependent on staff for bowel continence. R25's MDS, dated [DATE], indicates that R25 has bowel continence rated at 02: frequently incontinent. R25's MDS, dated [DATE], indicates that R25 has bowel continence of 02: frequently incontinent. R25's care plan, dated 9/14/2022, states, Bowel incontinence related to disease process, impaired mobility will be maintained in as clean and dry dignified state as possible, will have no skin breakdown, will have no complications and toilet upon rising, before/after meals, at bedtime and PRN (as needed). R25's care plan states, Resident is at risk for falls related to gait balance problems, history of falls. Fall related injuries will be minimized through care plan review date and resident to be toileted before and after meals. R25's care plan states, ADL self-care deficit as evidenced by reliance on staff related to: physical limitations, disease process of epilepsy and TRANSFER: Hoyer with assist of 2. Staff may use the ez-stand to toilet from broda chair to toilet only. Review of Certified Nursing Assistant (CNA) care Kardex, dated 5/9/24, states: BLADDER/BOWEL toilet upon rising, before/after meals, at bedtime and PRN and TRANSFER: Hoyer with assist of 2. Staff may use the ez-stand to toilet from broda to toilet only. Bowel Assessments Date: 11/7/2022 Bowel: 1. Continent of Stool? a. Yes 2. Bowel Pattern: a. Normal formed stool, rarely/never depends on laxative 3. Factors contributing to Fecal Incontinence e. Chronic laxative use 5. Comments: Noted to have incontinent BM since hospital admission. Description: Re-Admission Score: 16.0 Date: 12/26/2022 13:17 Bowel: 1. Continent of Stool? b. No 2. Bowel Pattern a. Normal formed stool, rarely/never depends on laxative Add: The assessment does not describe the type of fecal incontinence or contributing factors. There are no individualized interventions to assist R maintain is current level of bowel continence. R25's most recent bowel assessment, completed 12/26/2022, shows R25 is not continent of bowel. The bowel assessment does not describe the type of bowel incontinence or contributing factors. There are no individualized interventions to assist R25 in maintaining current level of bowel incontinence. Surveyor did not locate any other bowel assessments since 12/26/22. Review of bowel tracking look back for 30 days describes type, frequency, consistency, and patterns of bowels but does not contain information about type of bowel incontinence or patterns of bowel movements to implement an individualized bowel toileting program. Review of fall incident reports show that R25 has had 2 falls when getting up unassisted related to having to go to the bathroom/incontinent of bowel. Observations of R25 on 5/7/24 are as follows: 7:29 AM R25 was observed lying in his bed fully dressed with a Hoyer pad underneath him. 7:40 AM CNA F entered R25's room with Hoyer lift then left. 7:43 AM CNA F and another CNA entered R25's room. 7:48 AM Both CNAs left room with R25. R25 was in a Broda chair with blanket on his lap. 8:21 AM R25 was observed in the dining room for breakfast. 8:26 AM Observations continued. 8:53 AM R25 was taken from dining room to his room and placed in front of the TV. No toileting was offered. 8:54 AM CNA F entered R25's room to remove the Hoyer lift. 9:11 AM CNA F entered R25's room with bed linens and dropped them off. No toileting provided. 9:23 AM-10:58 AM No toileting offered. The EZ stand was not brought into R25's room during this observation. 11:28 AM R25 was still in Broda chair. R25 was awake and moving around. R25 sat forward and scooted his bottom forward. R25's lower legs were on the outside of the elevated footrest. It appeared R25 was attempting to get out of the Broda chair but could not. R25 had a chair alarm attached to shirt. 11:31 AM, R25 continued to move back and forth in Broda chair. CNA F entered R25's room and closed the door. CNA F could be heard stating, Hi, what ya doing? The EZ stand lift was not brought into the room. 11:33 AM CNA F came out of room and walked down the hallway towards the nurse's station. 11:35 AM R25 was taken to the common area by front entrance. 11:35 AM - 11:49 AM Observation continued. 11:49 AM CNA F took R25 to the dining room for lunch. 11:49 AM-12:48 PM R25 was observed in the dining room. 12:48 PM CNA F took R25 out of dining room. 12:53 PM R25 was observed sitting in common area by front entrance. R25 was observed sitting in this area until 1:46 PM. 1:46 PM CNA F took R25 to his room. Another staff asked CNA F if CNA F needed help with R25. CNA F stated, No, just going to empty the catheter and reposition. 2:15 PM R25 was up in Broda chair in room. 2:40 PM Resident was still up in Broda chair in room. Continuous observation of R25 showed no toileting observed or offered. Observations revealed staff did not take an ez-stand into R25's room, only a Hoyer lift. R25 sat in his Broda chair all day, was never placed on the toilet with the ez-stand. Surveyor observed R25 all day until 2:40 PM. Review of R25's bowel elimination shows: Question 1: Bowel continence shows that on 5/7/2024 R25 was marked continent by CNA F at 2:05 PM and 2:12 PM. Observation of R25 by Surveyor during this period shows that CNA F had not brought an ez-stand into R25's room to place R25 on the toilet. R25 was observed up in the Broda chair between 1:46 PM when CNA F took R25 to his room after lunch and 2:40 PM when Surveyor last observed R25. On 05/08/24 at 8:30 AM, CNA G was informed Surveyor would like to observe toileting and cares for R25. CNA G came and got Surveyor for catheter care only, no toileting was provided for observation. On 05/07/24 at 1:10 PM, Surveyor interviewed CNA F regarding bowel incontinence and toileting for R25. CNA F stated, We take him to the bathroom, but he doesn't always tell us. He has certain physical things he does like lift butt, stretch legs out and move around in chair we look for. CNA F stated that R25 doesn't refuse the bathroom if taken and there has not been a decline in R25's incontinence. CNA F stated there has not been a change except that R25 had a regular catheter, but that was changed to a suprapubic, otherwise same incontinence. On 05/08/24 at 11:36 AM, Surveyor interviewed CNA G regarding R25's incontinence and toileting with ez-stand. CNA G stated that R25 is incontinent of bowel unless they can catch him in time to put on the toilet. When asked if R25 was toileted with ez-stand, CNA G stated that R25 will fidget in the chair and/or make faces when he must go to the bathroom. CNA G stated that if R25 is observed doing this then they will use an ez-stand and take him to the bathroom. CNA G stated they use the ez-stand for the bathroom only, otherwise resident uses a Hoyer lift. Neither CNA F nor CNA G stated they are supposed to toilet R25 per his care plan, only if they see these physical indications. On 05/08/24 at 3:32 PM, Surveyor interviewed Director of Nursing (DON) B regarding expectations of CNA staff toileting R25 per his care plan and interventions for R25's bowel continence. DON B stated that CNAs should be following R25's care plan and it is on their Kardex to ensure R25's ability to maintain current level of bowel continence and also an intervention to prevent falls.

Based on interview and record review, the facility did not ensure a care plan was developed for nicotine use for 1 of 2 residents (R) 1 reviewed for comprehensive care plans. This is evidenced by: The facility policy, entitled Comprehensive Care Plan dated 09/23/22, states in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents comprehensive assessment .2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed. On 03/19/24 at 8:30 AM, Surveyor conducted a record review of progress notes for Resident (R) 1. A note stating: 1/25/2024 03:41 .Behavior Note .Staff called to resident room tonight, found to be incontinent of stool .Staff began cleaning resident up, resident found to have multiple vape pens in his bed as well as a Dab pen and his phone. Staff cleaning resident and attempting to rolling him resident had to take a hit before moving. Staff then asked him to put them away as they were removing all bedding, which resident reluctantly complied. On 03/19/24 at 8:40 AM, Surveyor's record review of the care plan for R1 revealed no care plan for the resident related to nicotine products. On 03/19/24 at 10:03 AM, Surveyor interviewed R1 regarding the incident on 01/25/24. R1 said that R1 did wish to use tobacco products and now understands that R1 cannot use them in the building. R1 knew about the designated areas and said it did not bother them. R1 mentioned the new rule is that R1's materials are locked at the nurse's station, and R1 can access the smoking materials whenever R1 wishes. R1 usually took their smoking materials with R1 when leaving the facility with family. R1 did not see any problem with the current arrangement. On 03/19/24 at 11:05 AM, Surveyor interviewed Certified Nursing Assistant (CNA) E about R1's smoking habits. CNA E said CNA E did not even know that R1 used a vape or tobacco products. On 03/19/24 at 11:52 AM, Surveyor interviewed Registered Nurse (RN) M and RN K regarding the process for R1 to receive R1's smoking materials. RN M and RN K said that R1 will come to the nurse's station whenever R1 liked, and the materials can be checked out. This is typically when R1 is leaving with family. On 03/19/24 at 12:20 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B regarding R1 using tobacco products. After the nicotine products were discovered, NHA A and DON B put into place the lock box and made sure to let R1 know where and when R1 was allowed to use the products, as per their policy. R1 seemed agreeable and understood. Surveyor asked for R1's care plan related to nicotine use. On 03/19/24 at 12:39 PM, Surveyor interviewed DON B about the care plan. DON B said they did not have a care plan and when the incident occurred, they expected the Minimum Data Set (MDS) coordinator to update care plans and this was not being done. DON B said they would have expected the care plan to be updated in this instance.

Based on interviews and record reviews, the facility did not ensure that the resident environment remained as free of accident hazards as possible. The facility did not assess the resident's ability to use e-cigarettes after determining that the resident used nicotine products. This occurred for 1 of 2 residents (R) 1 reviewed for assessments related to nicotine use. This is evidenced by: The facility policy, entitled Smoking Policy dated 07/14/22, states in part: This center shall establish and maintain a safe resident environment, while maintaining resident rights, smoking or nicotine use will be limited to designated areas, supervision and safety plans . 1. Residents who smoke or use smokeless tobacco products shall have a Nicotine Assessment completed upon admission, quarterly, annual and PRN. Residents or responsible party must be in agreement to nicotine use . Unsafe practices will result in IDT review of Nicotine Assessment and care plan interventions. On 03/19/24 at 8:30 AM, Surveyor conducted record review of progress notes for Resident (R) 1. A note stating: 1/25/2024 03:41 .Behavior Note .Staff called to resident room tonight, found to be incontinent of stool .Resident initially couldn't remember why he put the light on, then remembered and stated he had an accident. Staff began cleaning resident up, resident found to have multiple vape pens in his bed as well as a Dab pen and his phone. Staff cleaning resident and attempting to rolling him resident had to take a hit before moving. Staff then asked him to put them away as they were removing all bedding, which resident reluctantly complied. On 03/19/24 at 8:40 AM, record review indicated that R1 had two nicotine safety assessments, with the most recent assessment on 05/10/23. The nicotine safety assessment indicated that R1 did not use nicotine or have cessation materials. The assessments were completed before the incident on 01/25/24. No further nicotine safety assessments were completed after the facility had knowledge R1 was using nicotine. On 03/19/24 at 10:03 AM, Surveyor interviewed R1 regarding the incident on 01/25/24. R1 said that they did wish to use tobacco products and now understands they cannot be used in the building. R1 knew about the designated areas and said it did not bother them. R1 then mentioned the new rule is that their materials are locked at the nurse's station, and R1 can access them whenever R1 wishes. R1 usually took their smoking materials with them when leaving the facility with family. R1 did not see any problem with the current arrangement. On 03/19/24 at 11:05 AM, Surveyor interviewed Certified Nursing Assistant (CNA) E about R1's smoking habits and CNA E said they did not even know that R1 used a vape or tobacco products. On 03/19/24 at 11:52 AM, Surveyor interviewed Registered Nurse (RN) M and RN K regarding the process for R1 to receive their smoking materials and safety. RN M and RN K said that R1 will come to the nurse's station whenever R1 liked, and the materials can be checked out. This is typically when R1 is leaving with family. On 03/19/24 at 12:20 PM Surveyor interviewed Nursing Home Administrator (NHA) A and Director Of Nursing (DON) B regarding R1 using tobacco products. After the nicotine products were discovered, they put into place the lock box and made sure to let R1 know where and when R1 was allowed to use the products, as per their policy. R1 seemed agreeable and understood. Surveyor asked for a smoking/nicotine safety assessment for R1. On 03/19/24 at 12:39 PM, Surveyor interviewed DON B about the smoking/nicotine safety assessment. DON B said DON B did not have a smoking/nicotine safety assessment related to R1's current use of nicotine and did not complete one after the incident on 01/25/24. DON B said DON B would have expected an assessment to be completed after the incident.

Based on observation, interview, and record review, the facility did not ensure Residents (R2 and R3) with pressure injuries/ulcers receives necessary treatment and services consistent with professional standards of practice to prevent infection for 2 of 3 residents reviewed for pressure injuries. LPN C (Licensed Practical Nurse) did not perform appropriate hand hygiene while providing wound care to R2. LPN D did not perform appropriate hand hygiene while providing wound care to R3. This is evidenced by: Facility policy 'Clean Dressing Change,' states in part: Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: 5. Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: d. Use no-touch techniques to remove ointments and creams from their containers (i.e. use tongue blade or applicator). Liquid solutions should be poured directly onto gauze sponges. 7. Wash hands and put on clean gloves. 8. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. 9. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered, take care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound). Pat dry with gauze. 14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. 16. Secure dressing. [NAME] with initials and date. 17. Discard disposable items and gloves into appropriate trash receptacle and wash hands. Example1 R2 was admitted on [DATE] with diagnoses that include, in part: Alzheimer's disease with late onset, dementia with psychotic disturbance, difficulty walking, weakness, and abnormalities of gait and mobility. R2 has pressure injuries to the left heel and left elbow that require the following treatments per R2's Physician Orders: L (left) heel dressing: Remove previous dressing. Cleanse with wound spray. Apply skin prep to wound edges and cover with hydrocolloid dressing. Hold dressing in place while it warms to secure. In the morning every Wed. (Wednesday), Sat (Saturday) for pressure injury, started 9/9/23. L elbow wound: Remove dressing. Cleanse elbow with soap and water. Cover area with island dressing. In the morning for pressure injury, started 9/7/23. On 9/26/23 at 10:28 AM, Surveyor observed LPN D (Licensed Practical Nurse) complete wound care on R2's left heel and left elbow. Surveyor entered R2's room and observed LPN D sanitize her hands and put on clean gloves. LPN D opened a waterproof pad on the overbed table. LPN D opened dressing change supplies, gauze, ace wrap, foam cushion, 4x4 gauze, island dressing and petroleum gauze dressing, placing them on the top of the waterproof pad on the overbed table. LPN D removed R2's arm from inside her sweater and removed the old dressing to the left elbow. LPN D cleansed the wound with wound cleanser and 4x4 gauze wearing the same pair of gloves. After cleansing R2's wound, LPN D removed gloves, sanitized hands and applied clean gloves. LPN D placed island dressing over wound. LPN D indicates that the area is measured every Wednesday. LPN D removed gloves, sanitized hands and applied clean gloves prior to moving onto the left heel wound. LPN D removed R2's sock, removed scissors from pocket, and cut the gauze to remove the dressing from R2's foot. LPN D used wound cleanser and 4x4 to clean R2's heel. LPN D removed gloves, sanitized hands, and applied new gloves. LPN D applied petroleum gauze and as LPN D was attempting to apply foam pad, LPN D dropped it on the floor. LPN D then removed gloves, sanitized hands, and left R2's room to get a new foam pad. LPN D returned, sanitized hands, applied clean gloves, applied foam pad to heel, and foot was wrapped in kerlix to hold in place. LPN D applied Coban wrap over kerlix. LPN D then removed gloves and sanitized hands. On 9/26/23 at 10:47 AM, Surveyor interviewed LPN D. Surveyor asked LPN D when hands should be washed during a dressing change. LPN D stated, Anytime you take off your gloves and anytime you touch anything. Surveyor asked LPN D if you should wash hands when going from dirty to clean. LPN D stated, I should have taken off gloves, sanitized my hands, and applied new gloves after taking off R2's dirty dressing and cleansing the wound with clean 4x4's. Surveyor asked LPN D about the scissors she was using during the treatment. LPN D stated, I should have sanitized them after cutting off the dirty dressing and cutting the clean dressing. Example 2 R3 was admitted the facility on 9/28/22 with diagnoses that include, in part: Vascular dementia, osteoarthritis right and left shoulder, secondary parkinsonism, and muscle weakness. R3 has pressure injuries to the right elbow that require the following treatments per R3's Physician Orders: Right Elbow wound: Cleanse R (right) elbow wound with wound spray. Pat Dry. Apply Vaseline to peri wound. Cover with Mepilex. Every day shift for palliative wound care. On 9/26/23 at 10:55 AM, Surveyor observed LPN C (Licensed Practical Nurse) complete wound care on R3's right elbow. Surveyor entered R3's room and observed LPN C sanitize her hands and apply clean gloves. The old dressing was removed from R3's right elbow, clean gauze removed from package, then wound cleansed with wound cleanser and a 4x4 (gauze). LPN C removed her gloves, sanitized her hands, and applied clean gloves. LPN C took petroleum from the jar with a gloved finger and applied it to R3's right elbow wound bed. LPN C applied a foam bordered dressing, applied R3's elbow protector, and removed gloves. On 9/26/23 at 11:09 AM, Surveyor interviewed LPN C. Surveyor asked LPN C when to wash your hands during a dressing change. LPN C stated, Hands should be washed after cleaning and before putting on a new dressing. Clean gloves should be applied after cleansing and before touching the clean dressing. Surveyor asked LPN C if hands should be washed going from dirty to clean. LPN C stated, I should have removed gloves and washed/sanitized hands after taking off the dirty dressing and cleaning wound. On 9/26/23 at 1:38 PM, Surveyor interviewed DON B (Director of Nursing) and NHA A (Nursing Home Administrator) regarding expectation of hand hygiene with wound care. DON stated, Wash hands put on gloves. Remove dressing, take off gloves, sanitize hands. Apply clean gloves, wash/clean the area. Take off gloves, sanitize hands, apply new gloves, and then apply new dressing.

Based on interview and record review, the facility did not ensure that alleged violations involving abuse are reported immediately for 1 of 3 Residents (R2) reviewed for abuse. The facility filed a self-report on 6/17/23 regarding a staff member pushing R2 into a bedside table. The Housekeeper E did not immediately report the incident to their direct supervisor. Education was not provided to staff regarding abuse after the incident occurred. Evidenced by: The facility's policy and procedure entitled Abuse, Neglect and Exploitation dated 7/15/22, states, in part: Policy: It is the policy of this facility provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . III. Prevention of Abuse, Neglect and Exploitation . B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms . F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed . R2 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's Disease, prediabetes, kidney disease, anxiety disorder, and panic disorder. R2's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/7/23, indicates R2 has a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating R2 is severely cognitively impaired. R2 has an Activated Health Care Power of Attorney. Facility Misconduct Incident Report, dated 6/17/23, states, in part; Describe the incident .R2 was calling out and agitated. R2 was taken to her room. When wheelchair was pushed into the room, resident ran into tray table. Also, R3 was upset because R3 had asked for help to get out of bed, and CNA D (Certified Nursing Assistant) told her that she could get out of bed without help. Describe the effect .R2 had no recollection of the incident as she has severe cognitive impairment with a BIMS of 1/15. No injury noted upon skin review. Witness states that the wheelchair was forcibly pushed into room and R2 ran into the tray table at that time. R3 was initially upset, as she recalled the incident to son on Saturday, 6/17/23. R3 has no recollection of the incident as of Monday 6/19/23 when interviewed. No harm and CNA D was present while R3 transferred safely into her chair. Explain what steps entity took upon learning of the incident .Initially RN F (Registered Nurse) had placed CNA D on another hall after discussion with CNA D regarding R3. After incident with R2 and conversation with NHA (Nursing Home Administrator) CNA D was sent home pending investigation. Surveyor reviewed the timeline document that was attached to the self-report. Timeline states, in part: Notification of incident: On 6/17/23 at 1305 (1:05 PM), RN (Registered Nurse) NHA was notified by RN F, RN of R2 being agitated and calling out in the circle lounge. CNA D took R2 back to R2's room, so that other residents would not become agitated because of the calling out. Upon entering R2's room, RN F had heard R2 call out Ow! RN F asked R2 if R2 was ok. R2 continued with loud singing and ignored the question. RN F asked R2 what happened, R2 continued to sing loudly, as R2 does when agitated. RN F questioned CNA D. CNA D stated that R2 had run into the tray table. Skin assessment was completed; no redness, bruising, or open areas noted. Housekeeper E reported to RN F that CNA D then pushed the wheelchair into the room with excess force, causing the wheelchair to run into the tray table. CNA D was sent home pending investigation. During RN F's notification to RN NHA, it was noted that R3's son had told CNA that R3 was upset today because CNA D told her that she could get out of bed herself after R3 had asked for help to get up. Son reported that R3 indicated that she couldn't get up on her own and CNA D responded, Bullshit. RN F had questioned CNA D. Per RN F CNA D responded, I didn't say bull shit. RN F had CNA D go to work on the other hall, so that she wasn't working with R3 for the rest of the day . On 8/10/23 at 10:30 AM, Surveyor met R2. R2 made eye contact with Surveyor but did not verbally communicate. On 8/10/23 at 11:00 AM, Housekeeper E indicated on 6/17/23 she was talking with CNA D while CNA D was assisting R2 in getting ready for the day. Housekeeper E indicated the incident occurred a little before breakfast around 7:45 AM. Housekeeper E indicated CNA D was in a bad mood and seemed agitated. Housekeeper E indicated she left R2's bedroom and was in the hallway while CNA D finished assisting R2. Housekeeper E indicated CNA D walked out of R2's bedroom and R2 was behind CNA D pushing self in wheelchair. R2 started yelling and was right outside of her bedroom door. CNA D turned back around, spun R2 around so R2 was now facing towards bedroom, and CNA D then pushed R2 back into bedroom. Housekeeper E indicated CNA D pushed R2 with force and R2 ran into bedside table. R2 then yelled Ouch! Housekeeper E indicated at that time RN F came to the bedroom asking what happened. Housekeeper E indicated that CNA D lied to RN F about what happened and said that R2 ran into her table. Housekeeper E indicated she couldn't believe this had happened and was thinking about it all morning. Housekeeper E indicated she did not report it right away and reported incident during lunch time. Housekeeper E indicated she did not receive any education after the incident regarding abuse, challenging behaviors, or the importance of reporting possible abuse immediately. On 8/10/23 at 2:00 PM, RN F indicated she recalls the incidents from 6/17/23 because it was a hectic shift. RN F indicated on 6/17/23 a little before breakfast around 7:30-8:00 AM, RN F was down the hallway with med cart. RN F indicated she heard R2 yelling which is not uncommon. RN F indicated she saw from the corner of her eye someone coming out of R2's bedroom and then RN F heard R2 yell, Ouch. RN F went to R2's bedroom and CNA D indicated that R2 ran into bedside table. R2 appeared fine; a skin assessment was completed, and no concerns were identified. RN F indicated then around lunch time one of the other nurses came to RN F and said that Housekeeper E needed to talk to RN F. RN F indicated RN F and Housekeeper E went to the tub room and Housekeeper E reported to RN F that CNA D had lied about the incident with R2. RN F indicated she immediately contacted DON (Director of Nursing). RN F indicated she does not know why it took Housekeeper E so long to report the incident with R2. RN F indicated they all know the requirements of reporting allegations of abuse and that it should be done immediately. On 8/10/23 at 3:45 PM, DON B (Director of Nursing) and ADON C (Assistant Director of Nursing) indicated they were notified of the incident regarding CNA D on 6/17/23 from RN F. DON B indicated she instructed RN F to contact ADON C. ADON C indicated she did interview Housekeeper E, but must have forgot to write down the interview. ADON C and DON B indicated Housekeeper E should have immediately reported what she witnessed to her supervisor. ADON C and DON B indicated that Housekeeper E did not receive any education after this incident regarding the importance of reporting alleged abuse. Facility was not able to conclude that abuse occurred related to this incident.

Based on interview and record review, the facility did not have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 2 of 3 residents (R2 and R3). The facility did not interview all staff involved regarding an allegation of abuse for R2 and R3. The facility timeline of events does not match written statements from staff or Surveyor interviews. The facility failed to educate all staff after the investigation was concluded. Evidenced by: The facility policy titled, Abuse, Neglect and Exploitation, with a revised date, 7/15/2022, states, in part; .V. Investigation of Alleged Abuse, Neglect and Exploitation B. Written procedures for investigations include: 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation(s); 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation . Example 1 R2 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's Disease, prediabetes, kidney disease, anxiety disorder, and panic disorder. R2's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/7/23, indicates R2 has a Brief Interview for Mental Status (BIMS) score of 00 out of 15, indicating R2 is severely cognitively impaired. R2 has an Activated Health Care Power of Attorney. R2's Comprehensive Care Plan, dated 2/4/22, indicates, .in part; Verbal/physical agitation/aggression (verbal aggressiveness, pinching, striking out, yelling) r/t: cognitive impairment .Interventions .Allow resident time to respond to directions or requests. Approach slowly and slightly to the side .Gain residents attention before speaking or touching. Give resident clear, concise explanation of anything about to occur. If strategies are not working, leave (if safe to do so) and reapproach later .Talk in a low pitch, calm voice to decrease/eliminate undesired behavior. Facility Misconduct Incident Report, dated 6/17/23, states in part: Describe the incident .R2 was calling out and agitated. R2 was taken to her room. When wheelchair was pushed into the room, resident ran into tray table. Also, R3 was upset because R3 had asked for help to get out of bed, and CNA D (Certified Nursing Assistant) told her that she could get out of bed without help. Describe the effect .R2 had no recollection of the incident as she has severe cognitive impairment with a BIMS of 1/15. No injury noted upon skin review. Witnessed states that the wheelchair was forcibly pushed into room and R2 ran into the tray table at that time. R3 was initially upset, as she recalled the incident to son on Saturday, 6/17/23. R3 has no recollection of the incident as of Monday 6/19/23 when interviewed. No harm and CNA D was present while R3 transferred safely into her chair. Explain what steps entity took upon learning of the incident .Initially RN F (Registered Nurse) had placed CNA D on another hall after discussion with CNA D regarding R3. After incident with R2 and conversation with NHA (Nursing home Administer) CNA D was sent home pending investigation. Surveyor reviewed the timeline document that was attached to the self-report. Timeline, states, in part; Notification of incident: On 6/17/23 at 1305 (1:05 PM), RN (Registered Nurse) NHA was notified by RN F, RN of R2 being agitated and calling out in the circle lounge. CNA D took R2 back to R2's room, so that other residents would not become agitated because of the calling out. Upon entering R2's room, RN F had heard R2 call out Ow! RN F asked R2 if R2 was ok. R2 continued with loud singing and ignored the question. RN F asked R2 what happened, R2 continued to sing loudly, as R2 does when agitated. RN F questioned CNA D. CNA D stated that R2 had run into the tray table. Skin assessment was completed; no redness, bruising, or open areas noted. Housekeeper E reported to RN F that CNA D then pushed the wheelchair into the room with excess force, causing the wheelchair to run into the tray table. CNA D was sent home pending investigation. During RN F's notification to RN NHA, it was noted that R3's son had told CNA that R3 was upset today because CNA D told her that she could get out of bed herself after R3 had asked for help to get up. Son reported that R3 indicated that she couldn't get up on her own and CNA D responded, Bullshit. RN F had questioned CNA D. Per RN F CNA D responded, I didn't say bull shit. RN F had CNA D go to work on the other hall, so that she wasn't working with R3 for the rest of the day . It is important to note the timeline of events does not include an interview with Housekeeper E. It is also important to note the timeline does not align with written statements and Surveyor's interviews with staff. On 8/10/23 at 10:30 AM, Surveyor met R2. R2 made eye contact with Surveyor but did not verbally communicate. On 8/10/23 at 11:00 AM, Housekeeper E indicated recalling the incident from 6/17/23 between CNA D and R2. Housekeeper E indicated on 6/17/23 she was talking with CNA D while CNA D was assisting R2 in getting ready for the day. Housekeeper E indicated the incident occurred a little before breakfast around 7:45 AM. Housekeeper E indicated CNA D was in a bad mood and seemed agitated. Housekeeper E indicated she left R2's bedroom and was in the hallway while CNA D finished assisting R2. Housekeeper E indicated CNA D walked out of R2's bedroom and R2 was behind CNA D pushing self in wheelchair. R2 started yelling and was right outside of her bedroom door. CNA D turned back around, spun R2 around so R2 was now facing towards bedroom, and CNA D then pushed R2 back into bedroom. Housekeeper E indicated CNA D pushed R2 with force and R2 ran into bedside table. R2 then yelled Ouch! Housekeeper E indicated at that time RN F came to the bedroom asking what happened. Housekeeper E indicated CNA D lied to RN F about what happened and said that R2 ran into her table. Housekeeper E indicated she couldn't believe this had happened and was thinking about it all morning. Housekeeper E indicated she did not report it right away and finally reported it during lunch time. Housekeeper E indicated she did write a written statement, but no one interviewed her regarding incident. Housekeeper E indicated she has not received any further education or training regarding abuse, challenging behaviors, or the importance of reporting immediately. On 8/10/23 at 2:00 PM, RN F indicated she recalls the incidents from 6/17/23 because it was a hectic shift. RN F indicated on 6/17/23 a little before breakfast around 7:30-8:00 AM, RN F was down the hallway with med cart. RN F indicated she heard R2 yelling which is not uncommon. RN F indicated she saw from the corner of her eye someone coming out of R2's bedroom and then RN F heard R2 yell, Ouch. RN F went to R2's bedroom and CNA D indicated that R2 ran into bedside table. R2 appeared fine, a skin assessment was completed, and no concerns were identified. RN F indicated then around lunch time one of the other nurses came to RN F and said that Housekeeper E needed to talk to RN F. RN F indicated RN F and Housekeeper E went to the tub room and Housekeeper E reported to RN F that CNA D had lied about the incident with R2. RN F indicated she immediately contacted DON (Director of Nursing). RN F indicated a few moments after Housekeeper E reported this a family member for R3 came up and reported a concern with CNA D to another CNA. RN F was on the phone and after she got off the phone CNA reported R3's incident. RN F indicated she does not know why it took Housekeeper E so long to report the incident with R2. RN F indicated they all know the requirements of reporting allegations of abuse and that it should be done immediately. RN F indicated she had Housekeeper E write a written statement and CNA D was put on administrative leave. RN F indicated she did not personally interview staff or residents and that she wasn't sure if that was her responsibility to do so. RN F indicated she acted quickly once she knew of the incidents and reported to DON who directed her to contact NHA (Nursing Home Administrator). RN F indicated she has not received any education after this incident. On 8/10/23 at 2:41 PM, CNA D indicated CNA D remembers the incident on 6/17/23. CNA D indicated she found out about a week after that there were two concerns that were being investigated and it wasn't just about an incident with R3. CNA D indicated CNA D remembers putting R2 into her bedroom because she was screaming. CNA D does not remember R2 hitting bedside table. CNA D indicated she feels like she is being targeted. CNA D indicated she did have training on abuse before coming back to work. On 8/10/23 at 3:45 PM, DON B (Director of Nursing) and ADON C (Assistant Director of Nursing) indicated they were notified of the two incidents regarding CNA D on 6/17/23 from RN F. DON B indicated she instructed RN F to contact ADON C. DON B indicated she came into the facility on [DATE] and sent initial report into state agency. ADON C indicated CNA D was immediately put on administrative leave pending the investigation. ADON C indicated staff and residents were interviewed on Monday, 6/19/23. ADON C indicated she did interview Housekeeper E, but must have forgot to write down the interview. ADON C and DON B indicated all staff were not provided education after this incident. ADON C and DON B indicated housekeeping and kitchen staff do not have access to (online training program), so they would not typically receive the same training that is provided to nursing staff. This investigation regarding R2 was not a thorough investigation as the investigation did not contain all statements related to this incident. There is no evidence of staff being educated on abuse after this incident occurred as a corrective action to prevent from future occurrences. 45695 Example 2 R3 was admitted to the facility on [DATE] with diagnoses including: fracture of the sacrum, muscle weakness, difficulty walking, other abnormalities of gait and mobility, and unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decision, and solve problems). R3's quarterly MDS dated [DATE], indicated R3 has a BIMS of a 10 out of 15, indicated R3 cognitively moderately impaired. R3 needs extensive assistance with the support of one staff physical assistance with bed mobility, toileting, and transfers. R3 uses a wheelchair for locomotion. Record review did not indicate progress notes related to incident on 6/17/23. Skin assessments reviewed and completed on 6/14/23, 6/21/23, 6/28/23 noting no skin assessments completed on 6/17/23. No grievances reported related to this incident. On 8/10/23 at 2:08 PM, Surveyor interviewed RN F (Registered Nurse). Surveyor asked RN F to describe R3's incident. RN F indicated she went into R3's room to follow up on a family member's concern. RN F was informed by R3 that she had put her call light on to get out of bed, CNA D informed R3 that she could do it herself. R3 indicated to CNA D that she is supposed to put on her call light and ask for help, CNA D responded to R3 stating bullshit and then walked out of the room. RN F indicated that R3 could not remember the CNA's name and described her clothing for the day. RN F indicated R3's family came to her because when they arrived shortly after the incident that R3 was worked up. RN F indicated to the surveyor that R3 was trembling and tearful. RN F then conducted a meeting with all CNAs and CNA D admitted to declining to assist R3 and did not admit to swearing. Surveyor asked RN F if there was any formal follow up with R3's incident with CNA D, she indicated no. Surveyor asked RN F if a skin assessment was completed on R3, she indicated she did not recall. Surveyor asked RN F if there were any progress notes of R3's incident, she indicated she could not recall. Surveyor asked RN F if she submitted a written statement of the incident with R3, she indicated she thought she was asked to and did not recall if she did. Of note, no written statement was provided in the investigation for R3's incident. On 8/10/23 at 2:40 PM, Surveyor interviewed CNA D. Surveyor asked CNA D if she wrote a statement of the incident regarding R3 on 6/17/23, she indicated no. Surveyor asked CNA D if there was any further follow up or questions regarding the incident from administration, she indicated no further follow up was done and that she signed an abuse training. On 8/10/23 at 3:51 PM, Surveyor interviewed ADON C. Surveyor asked if skin checks were completed on R3, she indicated no and there should have been one done. Surveyor asked ADON C if skin checks were completed on residents that could not communicate, she indicated no. Surveyor asked ADON C if there were any other statements not included in the investigation, she indicated no. Surveyor asked ADON C if this was a thorough investigation, she indicated she thought it was. The incident with R3 was not thoroughly investigated as the investigation did not contain statements related to the incident with R3.

Based on observation, interview and record review, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, prevent new ulcers from developing, and a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable in 5 of 6 residents reviewed for pressure injury concerns (R1, 2, 3, 4, and 6). R1 has a history of PIs and had a current PI to his L heel, during the time reviewed. R1 complained of coccyx pain. The facility did not immediately do a thorough assessment into this pain and did not put additional interventions in place at the time of his initial complaint of pain to prevent injury. R1 developed a PI to this area, which advanced to a Stage III PI requiring debridement. The facility has no system to communicate appropriate settings for R2, R3, R6's air mattress', nor R4's air overlay mattress. In addition, Surveyor observed R4's heels not floated. The first example rises to a level G (actual harm/isolated) the other examples are not at the G level. This is manifested by: The facility's Policy and Procedure entitled Pressure Injury Prevention Guideline, with a most recent revised date of 4/2017, states, in part: Policy: Most PIs can be prevented. Four areas of clinical significance in PI prevention can include: 1. Identifying at-risk residents and the specific factors that place them at risk 2. Maintaining and improving tissue tolerance to pressure in order to prevent injury 3. Protecting against external mechanical forces (friction, shear, pressure) 4. Reducing the incidence of pressure injury through staff and resident education . .3. Prevention is the key to preventing skin breakdown . i) Heels should be positioned off the bed to avoid pressure . m) The resident's skin should be observed for areas of redness, heat, tearing, breaks or whiteness (blanching) 4. The RN will complete / document a weekly skin assessment TAR on all residents with a PI. Physicians need to be notified of all new PIs, when a pressure injury increases in size or fails to improve, and when a pressure injury heals . 7. Ongoing continuing education will be provided to staff regarding the characteristics of healthy skin, etiology of skin breakdown, risk associated with the development of pressure areas, importance of nutrition / activity / incontinence care, and interventions. 8. Treatments will be implemented with a physician's orders [REDACTED].>Example 1 R1's [DIAGNOSES REDACTED]. R1 was reviewed as a closed record. R1's most current Braden Scale, dated 10/20/17, is noted to give R1 the score of 13, indicating moderate risk (13 - 14) for PI. R1's most current MDS, with an observation end date of 10/20/17, documents that R1 is able to make himself understood, usually understands, has no problems with short or long term memory, and needs extensive assistance with bed mobility and transfers. In addition, this MDS documents that R1 is at risk for PI and has an unhealed PI, noted to be at a stage IV at the time of this observation end date. R1's care plan, at the time of his discharge on 11/11/17, shows a problem area which states: Impairment of skin integrity related to DM, [MEDICAL CONDITION], refusal of treatment / interventions, [MEDICAL CONDITION] manifested by . PI to posterior L ankle, history of skin breakdown to R (right) heel . generalized skin breakdown, PI to L heel, osteo[DIAGNOSES REDACTED] L foot . Interventions to this problem area include: Nurses . Assess skin condition daily and note any changes . treat as ordered . report any signs of skin breakdown i.e.; redness, open skin, etc. to nurse . Check and change q 2 hrs and as he requests . R1's record contains the following documentation: *10/2017 and 11/2017 TAR: Entries which state: Nursing Order: Monitor bottom for redness twice a day AM/ PM. For 10/2017, this Nursing Order was completed twice a day, as evidenced by staff initials, with the exception of 10/7/17 (AM), 10/8/17 (AM), 10/12/17 (PM), 10/13/17 (AM), and 10/21/17 (AM). For 11/2017, this Nursing Order was completed twice a day 11/1/17 - 11/10/17, as evidenced by staff initials. *10/13/17 Nurses Notes 5:30 PM: Readmission . after being admitted on [DATE] (to hospital) for chronic osteo[DIAGNOSES REDACTED] of the L foot, calcaneal, with no - healing wound . Has 3 areas on the R lower leg where top skin is off, which measure approximately 1.7 cm x 1.7 cm. No weeping noted from areas. Lower legs are firm and bumpy. Unstageable ulcer L heel is approximately 6.5 x 6.5 cm with wound bed 100% necrotic tissue. Edges of wound slightly macerated. Scant amount of drainage on dressing. Ulcer has foul odor Denies pain at this time . *10/13/17 Nurses Notes 5:37 PM: . Resident buttock was slightly red, but no open areas noted. (There is no evidence that new interventions or monitoring were initiated, or education was provided to R1 or facility staff when it was discovered R1 had a slightly red buttock. There is no evidence this red area was assessed to determine if this area was blanchable.) *10/14/17 Nurses Notes 5:21 AM: Resident returned from (hospital) on 10/13/17 after refusing any treatment to open area on L heel . *10/20/17 Nurses Notes 8:55 AM: Current pain level 5. How much of the time have you been experiencing pain or hurting over the last 5 days: (Answer) frequently Manner of expressing pain: (Answer) verbal Location of pain: (Answer) Buttocks . Current medications: [REDACTED]. Response to medications: [REDACTED]. Refuses to take any medications. *10/20/17 Care plan interventions added, which state: All staff - (R1) refuses to lay in bed most of the time despite education and multiple attempts to try different mattresses, and (R1) has been provided with a 42 inch wide long bed pressure reducing mattress. (It is important to note that with the exception of the slightly red observation, noted on 10/13/17, there has been no other description or assessment of R1's buttock despite having frequent pain to the area as documented on 10/20/17.) *10/24/17 Nurses Notes 1:50 AM: Resident was laying in bed from beginning of shift until about 1 AM when he started to have R knee pain and tailbone pain. States he can no longer sit in bed as it isn't comfortable. Resident repositioned a few times without relief. Resident was transferred to wheelchair per his request (Despite complaint of tailbone pain on 10/24/17, there is no evidence R1's tailbone area was visually assessed and no new interventions or monitoring added to R1's plan of care to prevent worsening of the area.) *10/25/17 Nurses Notes 6:40 AM: Resident has been in his wheelchair all night, refused to transfer to the recliner . *11/4/17 Nurses Notes 9:12 PM: . Resident has been in bed for past 24 hrs with feet elevated . Resident repositioned q 2 hrs and checked and changed q 2 hrs as well . *11/5/17 Nurses Notes 1:50 AM: Res (Resident) has been moaning and restless in bed . Skin clammy . *11/5/17 Nurses Notes 8:58 AM: Note: writer went into room and resident is laying in bed with head of bed up to 30 degrees . No facial grimacing or moaning noted . Writer touched resident on his L arm and resident had no response. *11/5/17 Nurses Notes 1:51 AM: . resident stated that he had pain, and when writer asked where, he stated, my ass. Writer offered pain medication and resident stated, No. Writer offered water at this time and resident did drink ice water. (Despite complaint of pain to his buttock region (ass) on 11/5/17, there is no evidence R1's bottom area was visually assessed and no new interventions or monitoring were initiated to prevent worsening of the area.) *11/5/17 Nurses Notes 8:20 PM: . Pressure area on bottom noted, [MEDICATION NAME] applied . Resident repositioned off his bottom side to side q 2 hrs and prn. Checked and changed q 2 hrs and prn. [MEDICATION NAME] offered prn and resident requested [MEDICATION NAME] x 2. Oxygen used throughout the shift. (This note was written by RN E.) (There is no evidence a physician was informed of this pressure area to R1's bottom on 11/5/17, and no evidence an order was obtained for the [MEDICATION NAME] treatment. In addition, a thorough assessment was not completed to document the size, depth, wound bed description, and stage of wound.) *11/6/17 Nurses Notes 12:44 PM: Spoke with attending physician regarding: Resident has a 2.5 x 3 cm skin tear on coccyx from fall on 11/3/17. Cleansed area with safe cleanse and placed [MEDICATION NAME] dressing to be changed q 3 days. Would you like any changes? May we have an order for [REDACTED]. new order received and noted 11/6/17 'yes' dated and signed 11/6/17. (This note was written by LPN F.) (On 11/6/17, R1's bottom is noted to have a skin tear. There is no mention of a PI to R1's bottom as noted on 11/5/17 by RN E.) *11/2017 TAR: 11/6/17 entry for Skin treatment: Cleanse coccyx with safe cleanse, apply skin prep to area, and then apply [MEDICATION NAME] dressing for protection every three days. This was completed on 11/6/17 and 11/9/17. *11/6/17 Nurses Notes 1:10 PM: Skin tear 2.5 cm x 3 cm cleansed with safe cleanse and skin prep to area, hydrodressing was placed over area to be changed every 3 days. (This note was written by LPN F.) *11/6/17 Nurses Notes 2:35 PM: . skin tear noted to coccyx. 2.5 cm x 3 cm area was cleansed with safe cleanse and skin prep applied. [MEDICATION NAME] dressing applied to area and will be changed q 3 days. (This note was written by LPN F.) *11/7/17 Care plan intervention added: Nurse Aides - (R1) has a Bariatric air mattress in bed. *11/9/17 Nurses Notes 8:39 AM: No changes in skin issues, black necrotic tissue around L heel with brown large serosanguinous drainage that has a ABD soaked in Dakins solution and wrap with Kerlix and cling and a skin tear on coccyx covered with [MEDICATION NAME] dressing. (No mention is made of R1's buttock skin condition despite the TAR indicating the [MEDICATION NAME] dressing had been changed on 11/9/17.) 11/10/17 Nurses Notes 8:01 PM: Duoderm changed on resident's coccyx. Resident noted to have some bleeding to coccyx, but became very verbally abusive to staff when repositioning him. He did not want to be placed on his right side very far. Resident repositioned from side to side q 2 hours this shift. Heels elevated with heel floater the entire shift as well. Resident was pre - medicated for all dressing changes this shift and for all repositioning as needed. (This note was written by RN E.) (There is no documented evidence a thorough assessment was completed on R1's coccyx wound to denote the size, depth, wound bed description, amount of bleeding and stage of wound. There is no evidence a physician was notified of this change of condition.) 11/11/17 Nurses Notes 4:56 PM: Resident discharged . Time of discharge 4:56 PM. discharged to: Acute care hospital (Name). On 11/11/17, R1 was transported to the area ED. Please note the ED's documentation states R1 arrived to the ED via ambulance transport at 2:01 PM. R1's 11/11/17 ED notes, state, in part: ED Course / Plan / Summary: This patient is brought by ambulance from nursing home because of L foot and sacral wounds. Exam: Large male appearing chronically ill. Afebrile, normal vitals. L foot is black on the entire heel with open skin which is draining pustular material. Sacrum has 6 cm diameter black area without open skin. X-ray of foot consistent with gangrene and osteo[DIAGNOSES REDACTED]. W C 26K. Given IV [MEDICATION NAME]. Transfer to (Hospital) Sacrum has 6 - 8 cm diameter black area without open skin . The ED's documentation states R1 was discharged from the ED at 5:30 PM. R1's Hospital History and Physical Notes, from 11/11/17, state, in part: Sacrum: 10 x 11 cm Decubitus ulcer, blackened, serosanguinous discharge . wound care consulted . R1's General Surgical Note, dated 11/12/17, states, in part: .he has a Decubitus ulcer, which also could benefit from debridement as well. All will be done in the operating room . R1's Operating Room Note, dated 11/12/17, states, in part: (Sacral Decubitus) was radically debrided including the underlying eschar . Sacrum with large wound . mostly granulation tissue to the base, but does have a rim of necrotic tissue to the superior wound edge . R1's Inpatient Discharge Summary, dated 11/16/17, states, in part: . Sacral Decubitus ulcer stage 2 -3. Present on admission. This too was debrided in the operating room. Wound care is managing this wound . On 12/6/17 at 9:45 AM, Surveyor spoke with RN G regarding R1 and his skin condition. RN G stated she does recall working with R1, but does not remember his coccyx being open. RN G stated if the TAR is signed off that R1's bottom was monitored, then a nurse would have been the one to look at the skin. On 12/6/17 at 10:15 AM, Surveyor spoke with RN H regarding R1 and his skin condition. RN H stated she recalls R1 having a skin tear to his coccyx approximately 1 cm x 1 cm. RN H stated it had been caused by the Hoyer sling. RN H stated it was red and slightly open and was being treated with a [MEDICATION NAME] dressing. RN H stated if the TAR has been signed out by the nurse that his bottom was looked at; it means it was looked at by the nurse. On 12/6/17 at 10:55 AM, Surveyor spoke with RN E via telephone regarding R1's skin condition. RN E wrote the note on 11/5/17 indicating R1 had a pressure area to his bottom. RN E stated R1 had a PI to his L heel as well as one on his bottom. RN E stated she saw it (the coccyx wound) after R1 had been given a shower. RN E stated it was not very big, stating it was about the size of a quarter. RN E stated she is not sure what stage it was, but that the wound bed was red and pink and not black. On 12/6/17 at 1:30 PM, Surveyor spoke with CNA I regarding R1 and his skin condition. CNA I told Surveyor that she does remember R1 having a PI to his bottom, but does not recall when that was. On 12/6/17 at 2:20 PM, Surveyor spoke with DON B regarding R1 and his skin condition. DON B stated R1 was very compromised and non - compliant regarding his care and treatment. DON B stated R1 had a skin tear and bruising to his bottom in the days before his discharge, which was the result of R1 sliding out of his chair. DON B stated this wound was approximately 2 cm long and it was not deep. DON B does not recall the last time he saw R1's buttock wound prior to his discharge. DON B went on to state that R1 was very non - compliant and did not want to lay in bed. DON B stated it was not until 11/7/17 when R1 agreed to start laying in his bed again. DON B stated R1's bed had an air mattress. DON B stated the facility does not have standing Wound Orders for wound care, and if a treatment is needed for a wound, the physician would need to be contacted. Surveyor asked DON B if a resident had a dressing that was to be changed q 3 days on his bottom, but also had an order to monitor the bottom for redness twice a day, would he expect staff to remove the dressing to look for redness on the bottom. DON B stated staff would look at the bottom, but not remove the dressing if the dressing were to only be changed q 3 days. On 12/11/17 at 9:30 AM, Surveyor spoke with RN J via telephone regarding R1 and his skin condition. Although RN J remembers R1, RN J does not recall caring for him in the days before his discharge, and does not recall if he had a PI to his coccyx. RN J stated it is not her practice to remove dressings that are to be changed every third day to note if the bottom is red. RN J stated she will inspect the bottom, but will keep the dressing intact until it is due to be changed. Surveyor's attempts to reach LPN F, who wrote the Nurses Note entry on 11/6/17 referring to R1's buttock wound as a skin tear, were unsuccessful. Message left for LPN F was not returned. Example 2 R2's MDS, completed 10/30/17, states she scored a 14 on the BIMS, indicating she is cognitively intact. R2's most recent Braden Score on 11/25/17 was a 17 indicating she is at risk for pressure ulcers. Her medical record states on 12/6/17, for her general skin condition, that her coccyx is reddened and bleachable. Reddened area with undefined edges. No open areas noted within reddened area. R2 denies pain or discomfort. Educated R2 to take rest periods in bed repositioning off buttocks in AM and PM. Recommend to continue current treatment as preventative measure. R2's care plan for Impaired Skin Integrity includes the interventions: 3/23/16 air mattress in bed, 7/24/17 Ensure air mattress is properly inflated. Her current Physician order [REDACTED]. On 12/5/17 at about 1:30 PM, Surveyor interviewed R2 who stated she has had bad sores on her bottom prior to coming to the facility, but now it is much better. Surveyor observed the air mattress on her bed and the setting was between 15 and 20. The manufactures guidelines indicate that it is an alternating pressure with low air loss mattress and that the setting between 15 and 20 is the minutes of loading and unloading cycles designed to maintain low interface pressures throughout the mattress, to redistribute peak interface pressures during the cycle. It does not include instruction of how to identify what setting it should be at for an individual. On 12/5/17 at 2:05 PM, Surveyor asked RN C how she knows what setting an air mattress should be set at for each resident. She stated it should be documented somewhere, but as she is new she would have to find out where. At 2:25 PM, RN C brought Staff D (Central Supply and Housekeeping) who explained that they could not find where it was identified for R2 what her air mattress should be set at. Staff D stated that she is the person who puts the air mattresses in place for residents and that nursing staff would then identify, with manufacture's recommendations, what the setting would be for each specific resident. On 12/5/17 at 3:35 PM, Surveyor asked DON B what the facility procedure was to identify what setting an air mattress should be set at for a resident. DON B stated he did not know. Surveyor asked if the facility had a policy/procedure for how to identify air mattress setting for residents. DON B was unsure if there was a policy for that, but said he would check. Upon completion of the survey on 12/6/17, Surveyor did not receive any further information. Example 3 R3's MDS, completed 9/12/17, indicates she has severe cognitive impairment. R3's most recent Braden score, completed 6/15/17, is 14, indicating she is a moderate risk for pressure ulcers. Her care plan for Impairment of Skin Integrity: high risk includes the interventions of a convertible air mattress on her bed. On 12/5/17 at 10:06 AM, Surveyor observed R3 in her bed with the air mattress set all the way to Firm. Surveyor reviewed the manufactures guidelines and it does not include instruction of how to identify what setting it should be at for an individual. On 12/5/17 at 2:05 PM, Surveyor asked RN C how she knows what setting an air mattress should be set at for each resident. She stated it should be documented somewhere, but as she is new she would have to find out where. At 2:25 PM, RN C brought Staff D who explained that they could not find where it was identified for R2 what her air mattress should be set at. Staff D stated that she is the person who puts the air mattresses in place for residents and that nursing staff would then identify, with manufacture's recommendations, what the setting would be for each specific resident. On 12/5/17 at 3:35 PM, Surveyor asked DON B what the facility procedure was to identify what setting an air mattress should be set at for a resident. DON B stated he did not know. Surveyor asked if the facility had a policy/procedure for how to identify air mattress setting for residents. DON B was unsure if there was a policy for that, but said he would check. Upon completion of the survey on 12/6/17, Surveyor did not receive any further information. Example 4 R4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R4's Braden assessment, dated 9/15/17, indicates R4 scored 12, indicating R4 is at high risk for PI development. R4 is unable to communicate. Section M0150, of the MDS, indicates R4 is at risk for developing PI's. Section G0110, Activities of Daily Living (ADL's), indicates R4 requires 2 staff and extensive assist for bed mobility and transfers. A Care Area Assessment (CAA) worksheet states: Resident (R4) is dependent on staff for her bed mobility. Repositioned every 2 hrs. Provided with an overlay on mattress. Heels elevated off bed as tolerated. Uses Broda when up. Wears arm protectors at all time d/t (due to) fragile skin. Incontinent of bowel and bladder. Checked and changed every 2 hours. [MEDICATION NAME] applied to buttocks TID (3 times a day). Power used in abdominal folds. She has a [MEDICAL CONDITION] brain disease, anxiety, depression. Receives [MEDICATION NAME] that could affect her mobility. No pressure ulcers at this time. No history of pressure ulcers. Continue current care plan - Impairment of Skin Integrity, high risk with goal of no skin breakdown. R4's Comprehensive Care Plan for Impairment of Skin Integrity: high risk. Related To: Incontinence, decreased mobility. Manifested By: Loss of positioning ability. Approach: Elevate heels off bed as tolerated . On 12/5/17 at 9:40 AM, Surveyor observed R4's right heel directly on the mattress. On 12/5/17 at 1:25 PM, Surveyor observed R4's right heel directly on the mattress. On 12/5/17 at 1:37 PM, Surveyor spoke with CNA C. Surveyor asked CNA C to observe R4's heels. Surveyor asked CNA C if R4's right heel is directly on the mattress. CNA C stated, Yes. CNA C stated, I don't want her heels on the mattress. CNA C then repositioned R4 so that her heels were floated. On 12/6/17 at 1:25 PM, Surveyor observed R4's Proactive Protekt Sire 1500 overlay set at 280 Firm. The facility has no system to communicate appropriate settings for air overlays and air mattresses. On 12/6/17 at 1:58 PM, Surveyor spoke with DON B. Surveyor asked DON B if he expects staff to follow resident care plans. DON B stated, Yes. Surveyor shared observations of R4's heels not floated. DON B agreed that R4's heels should be floated per her care plan. Example 5 R6 was admitted to the facility on [DATE], with Uncontrolled Diabetes Mellitus Type 2, Mixed Alzheimer's and [MEDICAL CONDITIONS], Lumbar Stenosis, [MEDICAL CONDITION], Sleep Apnea, Weakness, and [MEDICAL CONDITION]. R6's Braden assessment, dated 11/29/17, indicates R6 scored 17. R6's Braden assessment, dated 12/6/17, indicates R6 scored 13. Both scores indicating R6 is at risk for PI development. R6's Admission MDS has not yet been completed. R6's Comprehensive Care Plan for Potential for Impairment of Skin Integrity, dated 11/30/17: Approach: Assist with hygiene and general skin care, Air mattress to bed, Gentle approach when speaking to resident, Use incontinent pads. On 12/6/17 at 9:20 AM, Surveyor observed R6's Panacea Air Max AP Mattress set on 6 (firm). The facility has no system to communicate appropriate settings for air mattresses.

Based on record review and interview, in 1 of 13 total residents reviewed (Resident 1) the facility did not consult with a physician when a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications) and / or a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) occurred. On 3/11/13 at 9:00 PM Resident 1 was found to be pale, respirations 32, oxygen saturation of 85% and oxygen was started. These were all changes in condition for Resident 1. The facility did not contact the physician until 11:00 PM, when Resident 1 was found to be diaphoretic, color is ashen, oxygen saturation of 76%, oxygen was increased, respirations 56, blood pressure 200/80, pulse 130, temperature 99.4, and lungs are audibly wet and congested. Orders were given to send to the emergency room . Resident 1 was admitted to the hospital with [REDACTED]. Evidenced by: The American Medical Directors Association, Acute Changes of Condition in Long term Care settings a Clinical Practice Guideline indicates the following timelines in calling the physician in the following areas: *Vital signs: Respirations >28 per minute is to be reported to a physician immediately. *Respiratory rate: Abrupt increase in rate with dyspnea, pain, fever or respiratory distress is to be reported to a physician immediately. *Dyspnea: Acute onset of change from usual pattern, or with chest pain, labored respirations or unstable vital signs are to be reported to a physician immediately. Resident 1 was admitted to the facility 4/19/10 and readmitted [DATE] following a hospitalization . Resident 1's [DIAGNOSES REDACTED]. Resident 1 also has a history of aspiration. On 3/12/13 at 3:45 PM Surveyor reviewed the following information in Resident 1's medical record. Resident 1's MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 2/25/13, indicates Resident 1 has severe cognitive impairment, needs extensive assist of one person to eat, and has complaints or difficulty with swallowing. Resident 1's most recent Videofluoroscopic Swallow Evaluation, dated 1/31/12, includes the following: The patient remains at risk for aspiration, [MEDICAL CONDITION] and dehydrations as [MEDICAL CONDITION] progresses and dysphagia symptoms increase. Resident 1's nursing notes included the following entries: 3/12/13, 12:23 PM, Respiratory findings: Late entry for 3/11/13, 9:00 PM. Resident was anxious. Color pale. Respirations 32. Lung sounds unable to hear since resident was making noises. O2 (oxygen) sat (saturation) 85% on room air. O2 started at 2 L (liters) per NC (nasal cannula). 3/11/13, 11:13 PM, upon this nurse arriving to work for night shift, resident was extremely anxious and restless. Three CNA's (Certified Nursing Assistants) from PM shift were trying to keep him calm in the TV lounge. He continued to get more anxious and restless, and very loud and verbal with calling out and noises. Vitals were taken as follows: O2: 76%, on 3 L NP (nasal prongs), R (respirations): 56, BP (blood pressure) 200/80, P (pulse): 130, T (temperature) 99.4. Resident diaphoretic and color is ashen. ... Doctor called and received order to ship to hospital. ... Lung sounds are unable to be obtained due to resident's loud calling out behavior. Lungs are audibly wet and congested. ... Resident 1's hospital History and Physical, dated 3/12/13, included the following: History of Present Illness: ... This evening he developed respiratory distress after eating dinner. He was found to have a rapid respiratory rate and a pulse ox in the 70's despite oxygen supplementation at the nursing home. ... found to be in respiratory distress with initial respiratory rate in the 50's. He was placed on [MEDICAL CONDITION] ... The patient was initially given IV (intravenous) [MEDICATION NAME] without effect. Subsequently, he was started on IV antibiotics after blood cultures were drawn in the Emergency Department. He was admitted for treatment. Review of Systems: ... He was apparently coughing after dinner, thus aspiration is considered. ... Assessment and Plan: 2. Apparent aspiration pneumonia. The patient was started on [MEDICATION NAME] and [MEDICATION NAME] in the Emergency Department. I will change the [MEDICATION NAME] to [MEDICATION NAME]. Blood cultures are pending. Resident 1's chest x-ray, dated 3/11/13, included the following impression: There are multiple opacities involving the right midlung/right lung base. Some minimal airspace disease is also seen involving the left lung base. These findings are suggestive of pneumonia. On 3/14/13 at 10:30 AM Surveyor interviewed Registered Nurse (RN) F. RN F stated she worked with Resident 1 and completed the assessment on the PM shift 3/11/13. RN F stated the oxygen saturation was unusual for Resident 1. RN F stated she put the oxygen on Resident 1 due to the decreased oxygen saturation and increased respirations, as these were unusual for Resident 1. RN F stated she did not call the physician immediately because she thought the respiratory changes would resolve themselves with some oxygen. RN F stated he just kept getting worse. RN F stated she should have immediately contacted a physician due to the change in Resident 1's condition. On 3/14/13 at 10:45 AM Surveyor interviewed Director of Nursing (DON) B. DON B stated the facility follows the AMDA Guidelines as to when to notify a physician of changes in condition. DON B stated she would expect staff would call immediately for Resident 1's change in condition.

Based on observation, interviews, and record review the facility did not ensure that 2 (Residents 7 and 4) out of 12 residents reviewed for pain received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident 7 was readmitted to the facility following a hospital stay for acute onset of pain of unknown etiology. The facility did not adequately or consistently: * Provide prescribed medications prior to transfers and cares to promote comfort; * Assess the effectiveness of its pain treatment regimen; * Review the frequency of the need of prn (as needed) pain medications for breakthrough pain Resident 4 was observed exhibiting pain as demonstrated by facial grimacing and moaning when her leg was moved or touched during cares and treatments. The facility did not adequately assess pain, stop cares and provide pain relief before proceeding, consult with the physician, and update the plan of care to alleviate pain. This is evidenced by the following: The American Geriatric Society Guidelines: The Management of Persistent Pain in Older Person, indicates: Persistent pain is common in older people. The consequences of persistent pain among older people are numerous. Depression, anxiety, decreased socialization, sleep disturbance, impaired ambulation and increase healthcare utilization and costs have all been found to be associated with the presence of pain in older people. Persistent pain is an exhausting experience; deconditioning, sleep deprivation, and poor nutrition commonly result from unrelieved pain. A review of the facility Pain Guideline Policy dated September 2010 includes: Pain is a unpleasant sensory and emotional experience. 62% of nursing home residents have pain. Pain is one of the most common reasons for physician's visits. Certain conditions that can cause chronic pain are prevalent in the elderly; however the presence of pain is always abnormal (American Society of Consultant Pharmacists). The pain management program is based on the facility-wide commitment to resident comfort. "Pain management" is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Review the resident's treatment record or recent nurse's notes to identify any situations or interventions where an increase in the resident's pain may be anticipated, for example: *Bathing, dressing, and or other ADL's (Activities of Daily Living); *Treatments such as wound care or dressing changes; *Turning or repositioning. Strategies that may be employed when establishing the medication regime include: * Administering medications around the clock rather than PRN(as needed); * Combining long acting medications with PRN's for breakthrough pain; Example 1 Resident 7 was hosptalized on [DATE] and readmitted to the facility on [DATE] with the primary [DIAGNOSES REDACTED]. Resident 7's Significant Change MDS (Minimum Data Set) completed on 3/6/13 indicates Resident 7 has short and long term memory problems, and Severely Impaired cognitive skills for daily decision making. Resident 7 is a total assist of 2 for bed mobility, transfers, and toileting. Resident 7 is always incontinent of bowel and bladder. Section J0800 Staff Pain Assessment, indicated that Resident 7 indicates non-verbal sounds (crying, whining, gasping, moaning or groaning), Vocal complaints of pain(e.g. it hurts, ouch, stop), Facial Expressions (e.g. grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw), and Protective body movements or posture(e.g. bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement), and that Resident 7 has indicators of pain or possible pain daily. Resident 7's Pain CAA (Care assessment Area) with completion date of 3/7/13 indicates that Resident 7 was not able to verbalize her pain when pain interview was done. Resident 7 moans, calls out, grimaces, restless as signs of pain. On occasion she is able to say she has pain when asked. Was hospitalized and diagnosed with [REDACTED]. She has been receiving [MEDICATION NAME] 5 mg SL every hour which has been increased several times since return from the hospital, and started on PRN Loratab on 3/6/13. She has pain with movement of any kind. Will develop care plan- Alteration in Comfort with goal of resident showing signs of comfort. Review of Resident 7's care plan titled: Alteration in Comfort, dated 2/27/13, related to: DJD ([MEDICAL CONDITION] Joint Disease), [MEDICAL CONDITION], acute pain probably secondary to [MEDICAL CONDITION] arthritis, with underlying severe [MEDICAL CONDITIONS], manifested by: Showing pain, behaviors, crying or moaning. Approaches dated 2/27/13 direct staff to : monitor/record: med effectiveness, med side effects, document pain level, note characteristics of pain,, Resident 7 has a special air mattress, reposition Resident 7 for comfort every 1-2 hours, report pain to the nurse, and roho cushion in reclining wheelchair. On 3/7/13 the intervention Get up in recliner as tolerated was added to the care plan. On 3/11/13 review of Resident 7's physician orders [REDACTED]. 2/28/13: [MEDICATION NAME] 20 mg/ml 5 mg SL q 1 hrs prn for pain, 3/5/13: [MEDICATION NAME] 50 mg PO QD x 10 days for Cough/Pain then re-eval 3/6/13: Loratab 5/500 mg 1/2 tab q 4 hrs prn, Pain On 3/11/13 at 2:20 PM, Surveyor observed Resident 7 lying in bed on the special air mattress. Resident 7 was thrashing about in bed, pulling clothing off calling out "Help me, I hurt." Resident 7 was grimacing and eyes were closed. FM (Family Member) K was sitting at Resident 7's bedside in tears. *Please note that Resident 7 has an APOAHC (Activated Power of Attorney for Health Care) and FM K is the representative. Review of Resident 7's PRN pain medication Records indicate that on 3/11/13 from 9:05 AM to 10:30 PM Resident 7 received 6 doses of PRN [MEDICATION NAME] 5 mg (Milligrams) SL (sublingual), and 1 dose of Loratab 5/500 mg 1/2 tab. Review of Resident 7"s PRN medication sheets indicate the following: 3/11/13 at 6:50 AM- Loratab 5/500 mg 1/2 tab Reason: restless, intensity after medication: restless 3/11/13 at 9:05 AM- MSO4 ([MEDICATION NAME]) 5 mg, Reason: "Hurt", Pain intensity after medication: Sleeping 3/11/13 at 11:45 AM- MSO4 5 mg, Reason "Hurt", Pain intensity after medication: Restless 3/11/13 at 1:30 PM- MSO4 5 mg, Reason Pain, Pain intensity after medication: sleeping 3/11/13 at 5:15 PM- MSO4 5 mg, Reason: Pain, pain intensity after medication: sleeping 3/11/13 at 7:45 PM- MSO4 5 mg, Reason: Pain, Pain intensity after medication: sleeping 3/11/13 at 10:30 PM- MSO4 5 mg, Reason Anxious-crawling OOB (out of bed), Pain intensity after medication: sleeping It should be noted that the facility did not quantify the resident's pain prior to and after receiving the pain medication on a reproducible scale per current standards of practice. On 3/12/13 at 9:35 AM, Surveyor observed CNA (Certified Nursing Assistant) D and CNA M transfer Resident 7 from the recliner to the bed. Once the CNA's transferred Resident 7 into the bed and began rolling Resident 7 from side to side and positioned Resident 7 her right side with pillows and elevated heels off bed. Resident 7 began calling out "Oh my, Oh, Ouch! and holding her hand to her head. Resident 7 had her eyes closed and grimacing was noted on Resident 7's face, after the CNA's were finished with transferring and repositioning Resident 7, LPN (Licensed Practical Nurse) C then entered Resident 7's room and asked Resident 7 is she wanted pain medication, Resident 7 replied, "Oh Yes", LPN C then asked Resident 7 if she wanted [MEDICATION NAME], and Resident 7 replied, "Yes." On 3/12/13 at 9:55 AM, Surveyor interviewed LPN C regarding Resident 7's pain medications. LPN C stated that Resident 7 only gets PRN (as needed) [MEDICATION NAME] every hour, and that Resident 7's daughter wants the facility to keep Resident 7 comfortable. Surveyor then asked LPN C if Resident 7 was on any scheduled pain medication, and LPN C stated, "No." LPN C then stated, "I assess (Resident 7's) pain every 1.5-2 hours and document on the PRN medication sheet. I spoke with the DON (Director of Nursing) regarding updating the MD (Medical Doctor) today. I have also shared with another LPN regarding pain and giving the PRN more often. (Resident 7) did get pain medication this morning before cares; we try to give it to her before she gets up." A review of Resident 7's PRN medication sheets, for 3/12/13, notes the following: From 3:45 AM-11:15 AM on 3/12/13 Resident 7 received 4 doses of PRN MSO4 5 mg. 3/12/13 at 3:45 AM- MSO4 5 mg Reason: Pain- for TX (treatment), Pain intensity after medication: to bed 3/12/13 at 5:50 AM- MSO4 5 mg: Reason: Pain, Pain intensity after medication: in bed 3/12/13 at 10:00 AM- MSO4 5 mg: Reason: pain "Hurt": pain intensity after medication: sleeping - * Please note this administration is after Surveyor observed the transfer- Resident 7 was not pre-medicated prior to being observed by Surveyor . 3/12/13 at 11:15 AM- MSO4 5 mg: reason: Reports of pain, Results: Sleeping On 3/12/13 at 10:15 AM, Surveyor reviewed PRN MSO4 logs and interviewed MD (Medical Doctor) L regarding Resident 7's pain control. MD L stated, "(Resident 7) is a difficult case. I am going to schedule her [MEDICATION NAME] doses today, give her a lower dose more frequently to see if we get better control. I speak with (FM K) every day who said (Resident 7's) pain was better. The facility just called me this morning to have me come to look at (Resident 7). (Resident 7) has an [MEDICAL CONDITION] disorder and thought that aggressively treating the [MEDICAL CONDITION] disorder would help with the pain. I did not think (Resident 7) was going to make it she has been declining. There is a fine line between snowing and treating pain, I don't want to snow her." ** Review of MD L's progress note dated 3/12/13 at 11:00 AM reads: Schedule MSO4 2.5 mg S.L.q4hrs, D/C (discontinue) PRN MSO4** On 3/12/13 at 10:30 AM, Surveyor interviewed CNA D and CNA M regarding Resident 7's pain during cares provided. CNA D stated, "(Resident 7's) pain is better since on the [MEDICATION NAME], prior to (Resident 7) receiving the [MEDICATION NAME] Resident 7 was moving in the chair, crying, rubbing her legs. We were always told that (Resident 7's FM K) did not want (Resident 7) sedated so that when (FM K) visited (Resident 7'd FM K) could talk with her. Even when (Resident 7) was moved, (Resident 7) would be crying, placing the towels between (Resident 7) legs has helped a lot." CNA M then stated, "(Resident 7) was bad on the night shift too... bad. Bad. This morning (Resident 7) was much better, since she got the [MEDICATION NAME] before we got her up for breakfast." On 3/13/13 at 9:55 AM, Surveyor observed LPN C perform wound care to Resident 7's left heel ulcer. Resident 7 was sitting in the recliner with her eyes closed. LPN C stated, "I gave (Resident 7) an [MEDICATION NAME] a little bit ago, she has been so anxious." LPN C removed Resident 7's old dressing, and cleaned the area on Resident 7's left heel with wound cleanser, removed gloves, donned clean gloves and began measuring the length and width of Resident 7's left heel ulcer. Surveyor then asked LPN C what the depth of Resident 7's ulcer was, at that time Resident 7 began calling out "Oh, OH, Mama, Ouch", and pulled left foot away from LPN C. LPN C stated to Resident 7, "We are almost done." Surveyor then asked LPN C if LPN C was trained in measuring wounds, LPN C stated, "No not depth, I will have my DON (Director of Nursing) come down to figure out how to do the depth." Resident 7 began stating, "I hurt." LPN C stated to Resident 7, "It's not time for your medicine yet; I can give you some pain medication in a little bit." LPN C then removed gloves, washed hands and exited room at 10:03 AM. LPN C and DON B returned to Resident 7's room at 10:10 AM and measured the depth of Resident 7's left heel ulcer. Resident 7 again began stating, "Oh my, OH my," at which time DON B squatted next to Resident 7's chair, rubbing Resident 7's arm and asked Resident 7 if she hurt, to which Resident 7 replied, "Yes." LPN C finished applying the dressing to Resident 7's left heel ulcer, removed gloves, and sanitized hands. At 10:20 AM Resident 7 began moaning and DON B asked LPN C if Resident 7 could have anything for pain. LPN C stated to DON B, "I gave her [MEDICATION NAME] a bit ago. (Resident 7) is on scheduled now, and her next dose is scheduled for noon, I can give it at 11:00 AM." DON B then asked LPN C about PRN pain medications and LPN C stated, "Resident 7 has a Loratab (order) I can give her, this morning (Resident 7) refused all her oral medications." LPN C stated, "I just spoke with the MD and he increased the MSO4." DON B stated to LPN C, "Since the medication was changed you can give it now." Review of Resident 7's MAR for 3/12/13 indicates that Resident 7 received MSO4 2.5 mg SL at 8:00 AM, and the dressing change was done at 9:55 AM. No other PRN pain medication was administered. On 3/13/13 at 10:15 AM, Surveyor interviewed DON B regarding Resident 7's pain. Surveyor asked DON B if pain should be assessed during treatments, DON B stated, "Yes." Surveyor then asked DON B if residents are consistently using PRN pain medications what should the nurses do. DON B replied, "Get the medication scheduled". Surveyor then asked DON B if a resident is on a scheduled pain medication and it is not effective what should the nurses do? DON B replied, "Call the MD to get the dose changed. The nurses here are pretty new and not quite sure what to do, and there were some holdups with the family. The family did not want (Resident 7) to receive all the pain medication." On 3/14/13 at 9:50 AM Surveyor 2367 interviewed DON B regarding assessing pain for Resident 7 during the treatment observed on 3/13/13. DON B stated, "I would expect the nurse to assess a resident's pain before and during the treatment." DON B also stated, "(Resident 7) went to the hospital last night for pain control, she got worse. We feel we did everything we could." Example 2 The resource titled American Geriatrics Society Pharmacological Management of Persistent Pain in Older Persons, 2009 notes "An effective pharmacological approach to the treatment of [REDACTED]. Routine screening and careful assessment of all older patients is crucial, because pain that is causing severe impairment may not be spontaneously revealed for a variety of personal, cultural or psychological reasons...The current best indicator of the pain experience is the patient's own report which must include an assessment of the pain intensity and an evaluation of the effect of the pain on daily function." Resident 4 was admitted to the facility on [DATE]. Resident 4's current [DIAGNOSES REDACTED]. Resident 4's Physician order [REDACTED]. Resident 4's care plan titled Alteration in comfort, dated 1/15/13, indicates the following: Problem: Alteration in comfort related to right [MEDICAL CONDITION]. Manifested by Showing pain behavior, communication of pain description. Goal: Resident 4 expressed feelings of comfort or of pain relief. Approaches: A. Nurses; 1. Monitor/record: medication effectiveness, and medication side effects. 2. Document pain level. 3. Note characteristics of pain. B. Nurse Aide: 1. Position Resident 4 for comfort. 2. Assist with repositioning every 2 hours. 3. Report pain to the nurse. 4. Promote good rest. (Resident 4's care plan does not address Resident 4's pain due to Resident 4's right heel pressure ulcer, or pain during Resident 4's pressure ulcer treatments. Resident 4's comprehensive significant change of condition Minimum Data Set (MDS), completion date of 1/14/13 indicates the following: 1. B0800 - Ability to understand others. The area is mark as a 1 which indicates Resident 4 is able to usually understand others - misses some part of the intent of the message, but comprehends most of the conversation. 2. C0500 - Cognitive Summary score is a 5, which indicates Resident 4 has cognitive impairment. 3. J0100c - Pain management: Received non-medication intervention for pain. The answer was marked as 0 indicating no. 4. J0400 - Pain frequency the corresponding answer was mark as 1. Almost constantly. 5. J0500 - Pain effect on function: B. Have you limited your day to day activity because of pain. The answer was mark as 1- Yes. 6. J0600 - Numeric rating scale: Resident 4 to rate her pain over the last 5 days. Resident 4 described her pain as a level 5. (Indicating Resident 4 is able to rate her pain on a scale of 0 to 10.) Resident 4's Care Area Assessments (CAAs), dated 1/14/13, states Disease and conditions that may cause pain: Resident 4 has a right [MEDICAL CONDITION]. Characteristics of pain: Resident 4 has occasional pain in her right hip from her right [MEDICAL CONDITION] which causes her pain with movement. Resident 4 is able to tell staff she has pain if asked... Resident 4's pain documentation dated 1/11/13, states; Resident 4's current pain level; Not stated, Resident 4 grabs hip with care and movement. Resident 4 is not on a scheduled pain medication, and receives as needed pain medications. Resident 4 is able to make herself understood. Resident 4 she has had pain in the past 5 days and the amount of time Resident 4 has had pain is frequently. Resident 4's manner of expressing pain is verbal, facial expressions, and tightening... Resident 4's indicators of pain are facial expressions (grimaces, winces, wrinkled furrowed brow, clenched teeth or jaw.)... Resident 4's pain documentation dated 2/6/13, states; Resident 4's complained of right hip pain hurting at 5:00 PM. [MEDICATION NAME] given as ordered... On 3/12/13, at 9:37 AM, Surveyor observed Registered Nurse (RN) N perform a treatment to Resident 4's unstageable pressure ulcer to Resident 4's right heel area. RN N lifted Resident 4's right leg with her hand to remove the gripper sock and brown gauze type stocking from Resident 4's right heel area. Resident 4 had facial grimacing and verbalized in a loud tone Ouch that really hurts. RN N did not ask Resident 4's about the pain or stop the treatment process when Resident 4 complained about pain. On 3/12/13, at 9:40 AM, Surveyor observed RN N again lift Resident 4's right leg and spray skin prep to Resident 4's right heel unstageable pressure ulcer. Resident 4 again had a strong facial grimacing, verbalized the word Wow, that's the foot. Resident 4 then made a ooohhh noise as Resident 4 pulled her right leg away from RN N. RN N continued with the treatment without asking Resident 4 about her pain or stopping to relieve Resident 4's pain. On 3/12/13, at 9:40 AM, Surveyor observed RN N Lift Resident 4's right leg and reapply Resident 4's brown gauze type stocking, then RN N applied a lamb's wool heel booty and covered both items with a gripper sock. Resident 4 expressed a strong facial grimace, moaning of ooh, ooh, that foot hurts repeatedly and pulled her right leg again away from RN N. RN N finished Resident 's right unstageable pressure ulcer and placed Resident 4's leg on the heel lift device. RN N removed her gloved, washed her hands and left Resident 4's room. RN N did not ask to Resident 4 about her pain to her right leg prior to leaving Resident 4's room. Resident 4's nursing note, dated 3/12/13, at 10:00 AM, states Follow up right heel assessment... Ulcer status: Improving, Resident 4 reports that right heel is very tender. Current treatment: Spray skin prep to heel twice day, Lamb's wool heel protector... A pain assessment was not completed on Resident 4. On 3/12/13, at 11:00 AM Surveyor reviewed Resident 4's medical record to include use of scheduled and as needed medications. Resident 4 did not received pain medication prior to receiving her right heel treatment or after Resident 4 complained of right heel pain on 3/12/13 at 9:40 AM. On 3/13/13, at 8:45 AM Surveyor observed Certified Nursing Assistant (CNA) O transfer Resident 4 from the toilet to the wheel chair. Resident 4 stood with CNA O's direction. Resident 4's right foot was not placed directly on the floor. Surveyor observed Resident 4 to stand and pivot on Resident 4's tip toes. Resident 4 did not place her right foot base or heel on the floor during transfer. Resident 4 had a gripper sock covered with a lamb's wool heel protector on her right foot. Surveyor asked Resident 4 if her right foot hurt while she was standing. Resident 4 stated yes that's the one it hurts. On 3/13/13, at 8:50 AM Surveyor spoke with CNA O regarding Resident 4 walking on her tip toes. CNA O stated Resident 4's right foot is sore. Resident 4's right foot hurt when she places her foot on the floor. CNA P stated Resident 4 does it out of habit now due to her right foot being sore. On 3/14/13, at 8:05 AM Surveyor spoke with Director of Nursing (DON) B regarding facility protocol of pain management and pain management during pressure ulcer treatment. DON B stated the resident should be pretreated prior to pressure ulcer treatment completed. DON B also stated when a resident exhibits pain during a treatment the nurse should stop the treatment and ask the resident what type of pain the resident is having and given pain medication if needed. On 3/14/13, at 8:05 AM Surveyor spoke with DON B regarding when a pain assessment is to be completed. DON B stated on admission, quarterly and any change of condition. DON B also stated a new pain assessment is to be completed with any new onset on pain. Surveyor requested Resident 4's current pain assessment related to Resident 4's right heel pressure ulcer. No further information was present to Surveyor .

Based on observation, interview and record review the facility did not ensure that each resident received the necessary care and services to attain their highest practicable physical well-being in accordance with their plan of care for 1 of 7 residents (Resident 7) reviewed. Resident 7 has a care plan approach to assess for dehydration. On 11/17/11 Resident 7's Dietary Re-Admission Assessment identified Resident 7's fluid need to be 1,272 cc per day. From 11/17/11 to 1/30/12 Resident 7 did not meet her assessed fluid needs. The facility did not consistently assess Resident 7 for dehydration. The facility did not monitor Resident 7's total fluid intake for each 24 hour period to assess if her needs were met. On 1/9/12 Resident 7 had a BUN of 101mg/dl and a Creatinine of 2.99 ml/dl. The physician was not updated regarding the abnormal laboratory results until 1/10/12. On 1/10/12 Resident 7 was sent to the emergency room , diagnosed with [REDACTED]. Evidence by: The American Medical Directors Association (AMDA) Protocols for Physician Notification includes the following: Framework for Reporting Changes in Vital Signs or Laboratory Value to a Practitioner ... Chemistry, Report Immediately, Blood/urea/nitrogen (BUN) >60mg/dl. The facility's Nutrition/Hydration Policy, dated 7/2008, and indicates the following: *Guideline: All residents will receive effective nutrition and hydration to promote quality of life, ensure adequate intake and minimize weight changes. *Hydration: All residents will be assessed for dehydration risk factors within fourteen days of admission/readmission, annually and whenever a significant change occurs. *Warning Signs of dehydration: dry, cracked lips/mouth, sunken eyes, dark urine, decreased skin turgor, confusion/change in mental status, trouble swallowing liquids, vomiting/diarrhea, [MEDICAL CONDITION] lethargy/weakness, fever/constipation, dry coated tongue, decreased urine output, nausea/headache/dizziness, postural [MEDICAL CONDITION], need for assistance during meals, weight loss. *Thirst may or may not be present in elderly due to altered thirst perception. *Intake and Output will be completed on all new admission/re-admission for a minimum of three consecutive days (may be longer based on resident's status or condition). *For residents determined to be at high risk: Examples may include: ... Residents noted to have poor intake for several consecutive days. Resident 7 was originally admitted to the facility 9/28/10 and readmitted [DATE] after a hospitalization for pacemaker placement. Resident 7's [DIAGNOSES REDACTED]. Resident 7 has an activated Health Care Power of Attorney. Resident 7's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/11/11 indicates the following: Resident 7's cognitive status is moderately impaired. Resident 7 is independent with meal set up and eating. On 1/26/12 at 8:00 AM Surveyor observed Resident 7 in the dining room eating breakfast, no staff was present at the table. On 1/26/12 at 12:15 PM Surveyor reviewed Resident 7's medical record. The following information was found in Resident 7's medical record. Resident 7's Dietary re-admission assessment, dated 11/17/11, includes the following: ... 1272 - 1600 fluids per day using actual body weight. Medications: Same except added Oxybutinen. Resident 7's Nutrition Assessment, dated 10/26/11, indicated Resident 7 was on the medication [MEDICATION NAME], a diuretic. Resident 7's Care Plan Problem: Alteration in Elimination includes the following approaches, dated 11/7/11, encourage fluids, assess (Resident 7) for dehydration. Resident 7's physician orders, signed on 1/9/12, includes the following: 11/5/11, [MEDICATION NAME] (a diuretic)12.mg (milligram) daily for [MEDICAL CONDITION] (congested heart failure). 11/15/11, [MEDICATION NAME] (a diuretic) 60 mg qd (daily) for [MEDICAL CONDITION]. Monitor breath sounds and wt. (weight) daily. 12/13/11, check weight weekly. On 11/10/11 Resident 7's BUN (Blood/urea/nitrogen) was 35 and her Creatinine was 1.34. These results are both flagged on the report as H (high). A reference range for BUN is 7 - 25 and a reference range for Creatinine is 0.60 - 1.20 per the laboratory report. On 1/9/12 Resident 7's BUN was 101 and her Creatinine was 2.99 per her laboratory report. On 1/26/12 at 2:00 PM Surveyor reviewed Resident 7's Consumption Record. The facility's consumption record key includes the following: Record % (percentage) of total meal eaten: 1 = bites, 2 = 25%, 3 = 50%, 4 = 75%, 5 = 100% and 6 = refused. Resident 7's consumption record included the following entries: 1/1/12, Breakfast = 3, Lunch = 1, Dinner = 1 1/2/12, Breakfast = 5, Lunch = 1, Dinner = 6 1/3/12, Breakfast = 1, Lunch = 6, Dinner = 2 1/4/12, Breakfast = 1, Lunch = 1, Dinner = 1 1/5/12, Breakfast = 1, Lunch = 2, Dinner = 2 1/6/12, Breakfast = 4, Lunch = 6, Dinner = 1 1/7/12, Breakfast = 2, Lunch = 1, Dinner = 2 1/8/12, Breakfast = 3, Lunch = 1, Dinner = 2 1/9/12, Breakfast = 1, Lunch = 6, Dinner = 1 1/10/12, Breakfast = 1, Lunch = 2 Resident 7's Nurses Notes included the following: 1/4/11, 9:07 PM, Condition stability, resident had small emesis before supper. Resident eats bites for supper. Blood pressure 92/46 lying, pulse 81, respirations 24, O2 (oxygen) sat (saturation) 90% on room air, temp (temperature) 96.7. No further emesis. Son aware. 1/5/12, 1:34 PM, Actions: Call to (physician's name) made aware that resident's wt (weight) is down 6 lbs (pounds). Staff will start feeding resident. Resident seems more confused, not going to activities, more lethargic. 1/5/12, 2:32 PM ... more lethargic. 1/5/12, 10:56 PM, ... Only ate 25% of her supper. Still does not have much of an appetite. Note sent to MD (Medical Doctor) asking for labs to be checked. 1/6/12, 2:07 PM, Actions: return call from (physician's name) stating the [MEDICATION NAME] could be the cause of her lethargy and not eating. Orders received to change [MEDICATION NAME] order ... (physician's name) aware of wt. loss and stating to do orthostatic BP's (blood pressures) in relation to resident's need for decrease in [MEDICATION NAME] and fax to (physician's name). 1/6/12, 8:58 PM, ... Contact (physician's name) contacted regarding eating poor at meals and wt. loss. New orders received CMP (complete metabolic profile, this will include BUN and Creatinine) ... with next lab draw. 1/7/12, 1:15 PM, Cond. (condition) stability eating poorly and is encouraged to do as much as she is able ... 1/8/12, 9:58 PM, Cond. Stability resident had dark colored small emesis after supper ... 1/9/12 8:30 AM, Lab work: INR, CBC, CMP 1/9/12, 12:28 PM, Lab work: ...CMP returned - BUN elevated - 101. Creat (creatinine) 2.99 - other abnormalities noted also, INR elevated 0 5. Actions: Results faxed to MD (physician's name). 1/9/12, 4:40 PM, Physician Contact (physician name) contacted regarding INR 5.0. Stop [MEDICATION NAME] for 3 days. Recheck in 3 days. (HCPOA name) aware. 1/9/12 5:05 PM, Physician Contact (physician name) contacted regarding please d/c (discontinue) orders to do breath sounds weekly her breath sounds have been ok. We can do breath sounds with no order. d/c weekly wt order we can do this with no order and we do with [MEDICATION NAME] orders new orders received yes as above. (HCPOA name) aware. 1/9/12, 8:49 PM, Cond. Stability loose stool x1 (one time) on pm's (evening shift) 1/10/12, 5:57 PM, Condition noted: No void on noc (night) shift, oncoming RN made aware. 1/10/12, 11:05 AM, Condition noted: 7AM 2 calls by DON (Director of Nursing) to (physician's name) for eval (evaluation) of labs yest (yesterday) - no return call - called his home - no answer, cellphone - no voice box set-up and then message left at office. 8 AM meds (medications) held until eval of labs by a physician. 8 AM and 9 AM - call to (physician's name) - staff noting, physician in office - to eval and call - message left 8 AM meds not given. 9:30 AM labs refaxed and list of meds sent to (physician's name) office. (Physician's name) stating he will eval and call back. 10 AM call from (physician's name) to not give a 8 AM meds and transport resident for admit for IV therapy for kidney failure. 10:10 AM call to son ... 1/10/12, 12:25 PM, Condition noted: Return call from (physician's name) stating he will rehydrate resident with IV's (intravenous fluids) at the hospital and change her medications and resident will be transported back ... Resident 7's hospital physician progress notes [REDACTED]. 1/10/12, 1200 (12:00 PM), S: 88 y.o. (year old) white female resident of Sannes brought in b/c (because) recent labs showed dramatic increase in BUN (101) and creatinine (2.9). Pt (patient) has no complaints, but NH (nursing home) staff claim she has been more lethargic than usual. Stool guiac negative yesterday. O: Pt alert O x3 (oriented to person, place and date), flat affect, oropharynx dry, chest clear, car (cardiac): irreg (irregular) paced (pacemaker in place), abd (abdomen): non-tender, ext (extremities): no [MEDICAL CONDITION], skin turgor (arrow pointing down meaning decreased) ... A: 1. Dehydration 2. [MEDICAL CONDITION] ... P: IV fluids, D/C (discontinue) [MEDICATION NAME], transfer back to NH (c with line over meaning with) f/u (follow up) labs later this week ... On 1/31/12 at 7:40 AM NHA (Nursing Home Administrator) A provided Surveyor with Resident 7's daily input from 1/1/12 thru 1/30/12. The dates of 1/1/12 thru 1/9/12 were blank. Resident 7 did not meet her fluid needs on 20 of the 21 days for the dates of 1/10/12 thru 1/30/12. Resident 7's fluid intake ranged from 390 cc to 1410 cc with an average fluid intake of 888 cc for the dates of 1/10/12 to 1/30/12. On 1/30/12 at 2:40 PM Surveyor interviewed DON (Director of Nursing) B. DON B stated she would expect Resident 7's care plan approach, assess for dehydration, to be followed. DON B stated she would expect staff to monitor intake and output, weight, lung sounds, and [MEDICAL CONDITION] all daily. DON B stated that the facility does not look at summary of the intake of fluids of the entire 24 hours. DON B states that the facility should pay more attention to the 24 hour total intake on residents who are at risk for dehydration. DON B stated the nursing staff should have called the physician immediately to inform him of the abnormal BUN and Creatinine. Resident 7 has a care plan approach, dated 11/7/11, to assess for dehydration. Resident 7 was on diuretics. Resident 7's 24 hour intakes were not monitored. Resident 7 had an abnormal high BUN of 101 and Creatinine of 2.99 on 1/9/12. The BUN and Creatinine were not called into the physician until 1/10/12. Resident 7 was sent to the emergency roiagnom on [DATE] and diagnosed with [REDACTED].