Every finding on record at St Joseph Residence

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 4 residents (R) (R57, R18, R40, and R3) of 16 sampled residents.Certified Nursing Assistant in Training (CNAT)-D entered the dining room and placed a ice pack from R57's room on R57's knee. R57 was on enhanced barrier precautions (EBP). Without completing hand hygiene, CNAT-D then passed lunch trays and put clothing protectors on R18, R40, and R57.R18 was on EBP. CNA-E did not don a gown or gloves prior to transferring R18 from recliner to wheelchair.R3 was on EBP. CNA-E emptied R3's catheter bag and removed personal protective equipment (PPE). CNA-E then removed garbage from a can, opened the door, and exited the room without completing hand hygiene. Findings include: The facility's Handwashing - Hand Hygiene policy, dated 5/1/24, indicates: .1. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors .Indications for Hand Hygiene: 1. Hand hygiene is indicated: a. Immediately before touching a resident; .d. After touching a resident; e. After touching a residents' environment .Applying and Removing Gloves: .4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. According to the Association for Professionals in Infection Control and Epidemiology (APIC) website retrieved 10/2/25: Proper hand hygiene is the number one way to prevent the spread of infection. Everyone - healthcare professionals, patients, residents, families, and volunteers - should clean their hands thoroughly and at appropriate times to prevent the spread of disease. The facility's Enhanced Barrier Precautions policy, dated 4/26/25, indicates: EBP is used to prevent the spread of multidrug-resistant organisms (MDROs) to residents while performing direct high-contact care for residents with wounds regardless of a diagnosis of MDRO colonization. Personal protective equipment (PPE) such as gloves and a gown are applied prior to complete high-contact resident cares such as transferring. 1. On 9/29/25 at 12:06 PM, Surveyor observed lunch in the rehab dining room. Surveyor observed CNAT-D walk toward R57 with an ice pack and secure the ice pack on the pant leg of R57's left knee. (R57's medical record indicated R57 was on EBP due to a surgical incision on R57's knee.) Without completing hand hygiene, CNAT-D removed a lunch tray from the serving line and delivered it to a table where R57, R18, and R40 were seated. CNAT-D put a plate of food, beverages, a napkin, and silverware from the tray in front of R18. CNAT-D took the tray back to the serving line, removed another tray, and put a plate of food, beverages, a napkin, and silverware in front of R40. CNAT-D took the tray back to the serving line, retrieved 3 clothing protectors, and put the clothing protectors on R57, R18, and R40. CNAT-D removed another tray from the serving line and put a plate of food, beverages, a napkin, and silverware in front of R57. CNAT-D then took the tray back to the serving line. CNAT-D did not complete hand hygiene during the observation. At 12:10 PM, Surveyor interviewed CNAT-D who verified CNAT-D did not complete hand hygiene after putting an ice pack from R57's room on R57's left knee and before delivering lunch and putting clothing protectors on R57, R18, and R40. CNAT-D stated CNAT-D should have completed hand hygiene between interactions. On 10/1/25 at 12:52 PM, Surveyor interviewed Director of Nursing (DON)-B who was aware of the observation and verified CNAT-D should have completed hand hygiene. DON-B indicated the facility was working on staff education. 2. From 9/29/25 to 10/1/25, Surveyor reviewed R18's medical record. R18 had diagnoses including diabetes, localized edema, laceration of head, asthma, and cellulitis of the left lower limb. A Minimum Data Set (MDS) assessment completed 9/18/25 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R18 was not cognitively impaired. A care plan, dated 9/23/25, indicated R18 should be on appropriate isolation precautions due to a risk for infection. The facility's September 2025 resident infection surveillance log indicated R18 had cellulitis of the left lower extremity and was on EBP. On 9/29/25 at 1:24 PM, Surveyor observed an EBP sign inside the entrance of R18's room. After R18 activated the call light, CNA-E entered the room and R18 requested to be transferred from recliner to wheelchair. CNA-E moved a wheelchair in front of R18, assisted R18 with the transfer, and wheeled R18 out of the room. CNA-E did not don PPE prior to the transfer. On 9/29/25 at 1:25 PM, Surveyor interviewed CNA-E who was not sure if R18 was on EBP. CNA-E then read the precautions sign in R18's room and indicated CNA-E should have worn a gown and gloves during the transfer. On 9/29/25 at 1:28 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-I who verified R18 was on EBP and CNA-E should have worn a gown and gloves to transfer R18. On 10/1/25 at 9:29 AM, Surveyor interviewed DON-B who verified R18 was on EBP and confirmed CNA-E should have worn a gown and gloves during the transfer. 3. From 9/29/25 to 10/1/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including breast cancer, lung cancer, and femur fracture. An MDS assessment completed 9/12/25 had a BIMS score of 14 out of 15 which indicated R3 was not cognitively impaired. A care plan, revised 9/16/25, indicated R3 had an indwelling catheter. The care plan contained an intervention, revised 8/26/25, that indicated R3 was on EBP. On 9/30/25 at 1:26 PM, Surveyor observed CNA-E empty R3's catheter drainage bag. After CNA-E emptied the bag, CNA-E walked into the bathroom and removed CNA-E's gown and gloves. CNA-E then bagged the garbage, opened the door, and walked into the hallway. CNA-E did not complete hand hygiene after removing PPE prior to or after exiting the room. When Surveyor interviewed CNA-E and asked about hand hygiene, CNA-E indicated CNA-E was going to look for hand sanitizer in the hallway. When asked if there was hand sanitizer in R3's room, CNA-E re-entered the room, noted there was a hand sanitizer dispenser on the wall, and completed hand hygiene. On 9/30/25 at 2:04 PM, Surveyor interviewed DON-B who confirmed CNA-E should have completed hand hygiene after removing PPE and exiting R3's room.

Based on staff interview and record review, the facility did not ensure the coordination of Hospice services for 1 resident (R) (R3) of 1 sampled resident.R3 received Hospice services. R3's medical record did not contain a current Hospice care plan and Certified Nursing Assistant (CNA) visit notes were not accessible. In addition, the facility did not coordinate or document bed baths and offer range of motion (ROM) exercises per R3's request.Findings include:The facility's contract with Hospice Company (HC)-J, dated 5/1/21, indicates: Services to be provided by Hospice: .2. Hospice will develop .a plan of care for the management and palliation of the resident's terminal illness .The plan of care will be updated as often as the patient's condition requires, but no less frequently than every 15 days. Part III: Services to be provided by Facility: .2. Facility will provide room and board services to Hospice patients who are residents of the facility, including but not limited to .personal care, and such other residential care services that are customarily provided by the facility to its residents. The facility acknowledges and agrees that it is the facility's responsibility to continue to furnish 24-hour room and board care meeting the personal care and nursing needs that would have been provided by the primary caregiver at home at the same level of care provided before Hospice care was selected and that the facility will provide all of the room and board services which the facility normally would have provided in the absence of the Hospice program. The facility further acknowledges and agrees that it is the facility's responsibility to meet the Hospice patient's personal care and nursing needs in coordination with the Hospice representative to ensure the level of care provided is appropriate based on the individual Hospice patient's needs. From 9/29/25 to 10/1/25, Surveyor reviewed R3's medical record. R3 was admitted to the facility on [DATE] and had diagnoses including breast cancer, lung cancer, and femur fracture. A Mimimum Data Set (MDS) assessment completed 9/12/25 had a Brief Interview for Mental Status Score (BIMS) score of 14 out of 15 which indicated R3 had intact cognition. R3 made R3's own medical decisions. A care plan, initiated 3/20/25, related to comfort care/end of life indicated R3 received Hospice services from HC-J. A hospice care plan in R3's medical record was dated 6/25/25 through 9/2/25. R3's current Hospice care plan was not in R3's medical record.On 9/29/25 at 10:51 AM, Surveyor interviewed R3 who cofirmed R3 received Hospice services but indicated R3 didn't always receive scheduled baths. R3 also indicated R3 requested to have daily lower extremity ROM exercises which were not always provided. In a subsequent interview on 10/1/25 at 9:00 AM, R3 clarified that R3 wanted a full bed bath for bathing because R3 did not want to get out of bed. R3 indicated only Hospice staff offered bed baths and sometimes ROM exercises were completed by Hospice or facility staff. Surveyor reviewed R3's bathing records from July 2025 to the present which included facility bathing records and Hospice notes. R3's facility bathing records indicated bed baths were provided on Monday and Wednesday AM by Hospice. The bathing records indicated R3 received a bed bath on 7/2/25, 7/9/25 and 7/16/25. Not applicable was documented for 8/6/25, 8/20/25, and 8/27/25. Total dependence was documented for 7/23/25, 7/30/25, 9/17/25, and 9/24/25. There was no charting for 8/13/25, 9/3/25, and 9/10/25. HC-J bed bath records contained Certified Nursing Assistant (CNA) notes that documented bed baths on the same days the facility documented bed bathsSurveyor reviewed HC-J nursing notes in R3's medical record but did not see any CNA notes.A Hospice progress note, dated 7/28/25 at 11:02 AM, indicated it was discussed and written in R3's notebook that a named staff will do ROM exercises with R3 during every visit.A Hospice progress note, dated 9/3/25 at 3:58 PM, indicated R3's bilateral lower extremities had edema. Family was concerned that R3 did not receive ROM exercises because R3 could not remember. The writer informed R3 and R3's family that the Hospice CNA usually provides ROM exercises with cares when the CNA visits.On 10/1/25 at 9:21 AM, Surveyor interviewed Restorative Aid (RA)-K who worked as a CNA on the weekend. RA-K indicated R3's family told the nurse that R3 was supposed to receive ROM. The nurse asked if RA-K worked with R3. RA-K indicated R3 was not and had not been on RA-K's restorative list. R3's care plan did not indicate R3 wanted to receive daily ROM exercises.On 10/1/25 at 9:51 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R3's medical record did not contain an updated Hospice care plan or CNA Hospice notes. DON-B indicated HC-J removed the physical binders and switched to a computer charting system. DON-B indicated the facility was not provided with the notes. DON-B indicated facility staff should offer a bed bath once weekly and Hospice staff should offer the second bed bath. DON-B indicated CNA staff documented NA for bathing when R3 refused and informed staff they need to document refused instead. When Surveyor indicated facility staff documented bed baths on the same days Hospice staff documented, DON-B was not sure which staff provided the bed bath. DON-B confirmed improvement was needed for offering and documenting bed baths. DON-B stated DON-B would follow-up with R3 and Hospice staff regarding ROM and indicated if staff provide ROM it should be in R3's care plan.

Based on observation, staff and resident interview, and record review, the facility did not ensure appropriate respiratory care and services were provided for 2 residents (R) (R18 and R28) of 2 sampled residents. R18 had a continuous positive airway ressure (CPAP) machine. R18 did not have an order to use the CPAP machine or orders to clean the face mask or tubing. R28 used a nebulizer machine. R28's nebulizer tubing was not changed according to the facility's policy. In addition, R28's medical record did not contain orders to change the nebulizer tubing or clean the face mask and other parts of the nebulizer. Findings include: The facility's CPAP/BiPAP (bilevel positive airway pressure) policy, dated 12/1/24, indicates to set the CPAP mode as prescribed, connect supplemental oxygen to the flow rate as prescribed, monitor oxygen saturation of the resident, and clean masks, nasal pillows, and tubing daily. The facility's Administering Medications Through a Small Volume (Handheld) Nebulizer document, dated 1/1/25, indicates: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway .Equipment and Supplies: .4. Nebulizer kit, including nebulizer, medication cut, T-piece, mouthpiece (or facemask), and tubing .Steps in the Procedure: .27. Rinse/clean the nebulizer equipment according to facility protocol .30. Change equipment and tubing every seven days, or according to facility protocol. 1.From 9/29/25 to 10/1/25, Surveyor reviewed R18's medical record. R18 had diagnoses including obstructive sleep apnea (OSA), diabetes, and asthma. A Minimum Data Set (MDS) assessment completed 9/18/25 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R18 was not cognitively impaired. A hospital Discharge summary, dated [DATE], indicated R18 had OSA and to continue using home device and settings. The discharge summary contained an order for oxygen 1 liter bled into sleep machine with all sleep. R18's plan of care, dated 9/23/25, did not indicate R18 used a CPAP machine. R18's Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not contain a physician order for the CPAP machine or indicate what settings to use. R18's MAR and TAR also did not contain orders to clean the CPAP and supplies or to monitor R18's oxygen saturation aside from a weekly vital signs order. On 9/29/25 at 10:24 AM and 1:46 PM, Surveyor observed a CPAP machine half-filled with water and a mask and tubing on R18's nightstand. Surveyor also observed a half-full gallon of spring water on R18's bed. Surveyor interviewed R18 who was not sure if staff are supposed to clean the CPAP machine and supplies. R18 indicated staff fill the machine with water provided by the facility. R18 indicated R18 used the CPAP machine at night and staff had not cleaned the mask or tubing. On 9/30/25 at 11:13 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated CNA-F only fills the machine with water and helps apply the mask if R18 requests. On 9/30/25 at 12:43 PM, Surveyor interviewed Registered Nurse (RN)-G who verified R18's medical record did not contain an order for CPAP use. RN-G was not sure if an order was needed to use the CPAP machine. On 9/30/25 at 12:44 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-H who indicated LPN-H offered R18 use of the CPAP machine but did not recall documenting the use. LPN-H verified R18's medical record did not contain an order for CPAP use and indicated LPN-H would get an order from the physician. LPN-H stated R18's medical record indicated R18 used the CPAP machine inconsistently at home. LPN-H indicated LPN-H would add orders for cleaning the CPAP machine/parts when LPN-H entered R18's CPAP orders on the TAR. On 9/30/25 at 12:48 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated the facility should have orders for CPAP use and cleaning. DON-B indicated when R18 was initially admitted on [DATE], R18 indicated R18 was not going to use the CPAP machine and did not bring the machine. When R18 was readmitted following a brief hospitalization, DON-B reviewed R18's hospital admission orders from 9/23/25 and noted an order for CPAP use. DON-B indicated the CPAP order should have been transcribed in R18's TAR. DON-B indicated nurses should clean the mask and tubing daily 2. From 9/29/25 to 10/1/25, Surveyor reviewed R28's medical record. R28 was admitted to the facility in October of 2024 and had a diagnosis of chronic obstructive pulmonary disease (COPD). R28's medical record contained an order for ipratropium-albuterol solution 0.5-2.5 milligrams (mg)/3 milliliters (ml) (used to relax and open the airways to improve breathing in people with COPD), inhale orally every 8 hours as needed for COPD via nebulizer (start date 5/19/25.) Surveyor reviewed R28's MAR for 9/19/25 to 10/1/225 and noted the nebulizer treatment was administered on 9/25/25, 9/26/25, 9/27/25, and 10/1/25. On 9/29/25 at 11:46 AM, Surveyor observed a nebulizer machine with tubing attached on R28's night stand. The tubing contained a piece of tape that was dated 9/19. Surveyor also observed an oxygen concentrator with tubing attached to a nasal canula that R28 was using. The tubing contained a piece of tape that was dated 9/27. On 10/1/25 at 9:43 AM, Surveyor interviewed LPN-C who verified R28's medical record did not contain orders to change the nebulizer tubing or clean the mask. LPN-C stated an order to change oxygen tubing is usually combined with a nebulizer tubing order and the night shift nurse changes both sets of tubing weekly at the same time. LPN-C stated the mask and parts should be disconnected, rinsed with water, and left to dry after every use and the tubing should be dated when changed. On 10/1/25 at 9:46 AM, Surveyor and LPN-C observed R28's nebulizer and oxygen tubing. LPN-C verified the nebulizer tubing was dated 9/19 and the oxygen tubing was dated 9/27. The nebulizer mask and connector appeared to be drying on paper towel on R28's dresser from the last administration in the early morning of 10/1/25. On 10/1/25 at 10:57 AM, Surveyor interviewed DON-B who stated the facility usually combines orders to change oxygen and nebulizer tubing and indicated the order should be on a resident's TAR. DON-B verified R28's TAR did not contain an order to change nebulizer or oxygen tubing. On 10/1/25, Surveyor noted R28's medical record was updated on 10/1/25 with an order to change nebulizer tubing and mask/pipe weekly every night shift every Saturday (start date 10/4/25 at 10:30 PM.)

Based on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 residents (R) (R1 and R2) of 8 sampled residents.On 6/27/25, R1 and R2 were struck by Family Member (FM)-C) in the dining room. FM-C aggressively grabbed at R1, pulled R1 in, and hit R1 in the mid-section with a closed fist. FM-C also slapped R2 on the right hand, grabbed R2's left hand, and pulled R2's wheelchair toward FM-C. The facility did not notify local law enforcement of the abuse.Findings include:The facility's Abuse Prevention and Response policy, revised 1/1/25, indicates: 1. Upon receipt of an allegation or report of an incident, the licensed staff and/or Social Services will .1.3 Contact the police department if there is a suspected crime against a resident. (The facility's policy did not include examples of crimes that should be reported, including but not limited to assault and battery, and did not indicate the facility consulted with local law enforcement to discuss what to report or not report.)On 8/15/25, Surveyor reviewed a facility-reported incident that indicated FM-C was in the dining room with R1 and R2 on 6/27/25 and became upset when R1 did not eat beans that FM-C brought from home. The investigation indicated Certified Nursing Assistant (CNA)-D witnessed FM-C aggressively grab at R1, pull R1 in, and swing at R1's mid-section with a closed fist. Staff also witnessed FM-C swat at and hit R2's right hand, grab R2's left hand, and pull R2's wheelchair toward FM-C as R2 attempted to roll away. Staff removed R1 and R2 from FM-C's vicinity following the incidents.The facility completed resident interviews, psychosocial assessments, and psychosocial monitoring on 6/27/25. The facility also completed psychosocial monitoring for R1 and R2 for 3 days post-incident. Nursing Home Administrator (NHA)-A spoke to FM-C about the incidents which did not appear to have affected R1 or R2. On 8/15/25 at 10:34 AM, Surveyor interviewed NHA-A who indicated R1 and R2's [NAME] of Attorney (POA) did not want to proceed with charges regarding the incidents. NHA-A did not feel the abuse should be reported to local law enforcement. NHA-A also confirmed the facility had not had a formal discussion with local law enforcement to determine what local law enforcement wanted the facility to report and/or what was considered a crime.

Based on staff interview and record review, the facility did not ensure an allegation of abuse was reported to the State Agency (SA) in a timely manner for 1 resident (R) (R1) of 1 sampled resident. On 10/15/24, R1 reported an allegation of abuse that involved a Certified Nursing Assistant (CNA). The facility did not submit an initial or five-day report to the SA in a timely manner. Findings include: The facility's Abuse Prevention and Response policy, with a review date of 9/23/23, indicates: Any person who becomes aware of alleged abuse, neglect or mistreatment .shall immediately report to the Executive Director .The Executive Director is responsible for receiving allegations of mistreatment, abuse, concerns, and complaints and ensuring the required investigation, reporting and resolution is completed according to State and Federal requirements .External Reporting: .If the suspected allegation does not appear to have caused serious bodily injury to the resident, or there is not a reason to suspect a crime has been committed against a person receiving care in this facility, a report will be submitted to the Department of Quality Assurance (DQA) immediately, but no later then 24 hours after forming the suspicion or notification of the abuse allegation .Response: Initial incident report will be submitted to the Wisconsin Department of Health Services (DHS) within 24 hours of notification of the incident and the investigation documentation and conclusion submitted within 5 working days of the initial report. On 11/7/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and passed away on 10/26/24. R1 received Hospice services and had diagnoses including traumatic subdural hematoma with loss of consciousness, congestive heart failure (CHF), and cognitive communication deficit. R1's Minimum Data Set (MDS) assessment, dated 9/12/24, had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R1 had intact cognition. R1 had an activated Power of Attorney for Healthcare (POAHC). On 11/7/24, Surveyor reviewed a facility-reported incident (FRI) that indicated the facility was made aware of an allegation of abuse on 10/15/24 at 5:07 AM. The FRI indicated R1 reported to a student nurse that a CNA threw a wash cloth in R1's face when R1 was sleeping. R1 also alleged staff rolled R1 in a way that caused more sores on R1's buttock. Nursing Home Administrator (NHA)-A submitted an initial report to the SA on 10/16/24 at 11:10 AM. The initial report should have been submitted to the SA within 24 hours of when the facility became aware of the incident. The facility started an investigation on 10/15/24 and submitted the five-day investigation to the SA on 10/23/24 at 10:10 PM. The five-day investigation should have been submitted to the SA within 5 business days of the initial report. On 11/7/24 at 1:15 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed NHA-A and DON-B were aware the five-day report was submitted late. NHA-A was not available for interview at that time.

Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection as observed during the provision of care for 4 Residents (R) (R42, R31, R20, and R34) of 4 sampled residents. Staff did not wear a protective gown during wound care for R42. Staff did not wear the appropriate personal protective equipment (PPE) during an observation of high-contact care for R31 who was on enhanced barrier precautions (EBP). R20 had a history of methicillin-resistant Staphylococcus aureus (MRSA), a chronic wound, and a catheter. The facility did not place R20 on EBP. R34 had chronic bilateral leg wounds that required wound care by the facility. The facility did not place R34 on EBP. Findings include: The facility's Enhanced Barrier Precautions policy, dated 4/26/24, states: Enhanced Barrier Precautions apply to residents utilizing devices or with wounds but are not limited to urinary catheters .wound care for chronic wounds (i.e., pressure wounds, diabetic foot ulcers, unhealed surgical wounds, venous stasis ulcers, etc.) does not include shorter lasting wounds or wounds that result from an acute injury (i.e., skin breaks or tears covered with an adhesive bandage or similar dressing). Personal protective equipment (PPE) is used during high-contact resident care activities requiring enhanced barrier precautions (EBP) .Handwashing is performed and gloves and gown are applied prior to perform the high-contact resident care activity (as opposed to before entering the room). The facility's Enhanced Barrier Precautions signage indicates High-contact resident care activities include: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care. 1. From 8/5/24 to 8/7/24, Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] and had a stage 3 pressure injury on the left buttock. On 8/5/24 at 12:56 PM, Surveyor observed Registered Nurse (RN)-F provide wound care for R42. Surveyor observed an EBP sign on R42's bathroom door and a PPE cart inside R42's room. Surveyor observed RN-F sanitize hands and don gloves prior to wound care. Surveyor did not observe R42 don a gown prior to or during wound care. Immediately following the observation, Surveyor interviewed RN-F who stated staff should wear a gown and gloves during resident cares if a resident is on EBP. RN-F confirmed RN-F should have donned a gown prior to providing wound care for R42. 43361 2. From 8/5/24 to 8/7/24, Surveyor reviewed R31's medical record. R31 was admitted to the facility on [DATE]. R31's Minimum Data Set (MDS) assessment, dated 6/12/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R31 had intact cognition. R31's care plan, dated 8/1/24, indicated R31 had a lymphedemic cluster wound on the right lower extremity. R31 also had a care plan, dated 7/26/24, that indicated R31 had recurrent moisture-associated skin dermatitis (MASD) on the right buttock and an open wound. On 8/5/24 at 10:00 AM, Surveyor interviewed R31 who stated R31 had wounds on R31's bottom and leg. Surveyor did not observe a PPE cart or EBP sign outside R31's room. On 8/6/24 at 10:02 AM, Surveyor observed an EBP sign on R31's door and a PPE cart outside R31's room. Surveyor knocked on R31's door, entered the room, and observed Certified Nursing Assistant (CNA)-G apply lotion on R31's right lower leg. CNA-G was not wearing a gown. On 8/6/24 at 10:07 AM, Surveyor interviewed CNA-G who stated CNA-G was a Restorative Aide and R31 liked to have R31's leg lotioned following R31's walking program. CNA-G stated CNA-G noticed the PPE cart outside R31's door that day and had asked if CNA-G needed to wear a gown. CNA-G stated CNA-G was told CNA-G did not need to wear a gown during ambulation with R31 but needed to wear PPE during high-contact activities like toileting. On 8/6/24 at 10:18 AM, Surveyor interviewed R31 who stated the PPE cart outside R31's room was placed there yesterday (8/5/24) in the late afternoon. R31 was unsure why the PPE cart was there. 47248 3. From 8/5/24 to 8/7/24, Surveyor reviewed R20's medical record. R20 had diagnoses including paraplegia, intestinal infectious diseases (gastroenteritis and colitis), neuromuscular dysfunction of bladder with indwelling medical device, calculus in bladder, overactive bladder, history of methicillin-resistant Staphylococcus aureus (MRSA), stage 4 sacral pressure injury, and osteomyelitis of sacral wound (dated 8/2/24). R20's MDS assessment, dated 6/21/24, had a BIMS score of 15 out of 15 which indicated R20 had intact cognition. R20's care plan contained interventions to report urinary tract infection (UTI) symptoms and care for R20's Foley catheter per facility protocol. On 8/5/24 at 10:07 AM, Surveyor interviewed R20 who stated R20 had a Foley catheter and a pressure injury on R20's bottom. R20 stated staff provided care as needed, wore gloves during cares, and brought in gloves and bandages when they completed cares. Surveyor did not observe an EBP sign or a PPE cart outside R20's room. R20's medical record did not indicate R20 was on EBP for high-contact cares. On 8/5/24 at 12:30 PM, Surveyor did not observe an EBP sign or a PPE cart outside R20's room. On 8/6/24 at 9:46 AM, Surveyor observed an EBP sign inside R20's room and PPE and garbage bins outside R20's room. Surveyor interviewed R20 who stated nursing staff brought the sign and equipment bins the night before and began wearing gowns during cares. R20 stated nursing staff did not wear gowns before and R20 did not understand why they started now. 4. From 8/5/24 to 8/7/24, Surveyor reviewed R34's medical record. R34 had diagnoses including cellulitis of the right lower limb, pressure-induced deep tissue damage of the left and right hips, and type 2 diabetes. R34's MDS assessment, dated 6/6/24, had a BIMS score of 15 out of 15 which indicated R34 had intact cognition. R34's medical record indicated R34 had venous ulcers on the right lower extremity and an order to complete a 15 minute Epsom salt soak, cover wounds with abdominal gauze pads, and wrap with Kerlix twice daily. R34's medical record also indicated R34 was admitted with pressure injuries on the right and left gluteal crease/posterior thighs with orders to monitor and prevent the wounds from re-opening. R34's medical record did not indicate R34 was on EBP for high-contact cares. On 8/5/24 at 9:21 AM, Surveyor interviewed R34 who stated R34 had an open wound on the right leg and previous damage to the right and left hips that previously opened up. R34 stated staff brought in bandages to wrap R34's legs and wore gloves during cares. Surveyor did not observe an EBP sign or a PPE cart outside R34's room. On 8/5/24 at 12:40 PM, Surveyor did not observe an EBP sign or a PPE cart outside R34's room. On 8/6/24 at 7:55 AM, Surveyor observed an EBP sign in R34's room and PPE and garbage bins outside R34's room. On 8/6/24 at 10:31 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R20 had an active infection and should have been placed on EBP upon admission due to R20's wounds and Foley catheter. DON-B stated DON-B was not aware R20 had a history of MRSA infection (dated 5/16/24) upon R20's admission to the facility. DON-B stated DON-B conducted an audit of all residents who should be placed on EBP and discovered on 8/5/24 that R20 and R34 should be on EBP but their care plans did not indicate EBP was required. DON-B stated nursing staff were educated on when EBP is required which is during any personal contact such as transfers, personal cares (including washing and lotioning), toileting assistance, brushing teeth, wound care, and catheter care. DON-B stated nursing staff should implement EBP when a resident receives cares or is touched during cares and assistance.

Based on observation, staff interview, and record review, the facility did not ensure the correct amount of Jevity 1.2 (a nutritional meal supplement) was administered for 1 Resident (R) (R7) of 1 sampled resident. On 8/6/24, Surveyor observed Licensed Practical Nurse (LPN)-D administer one 237 mL (milliliter) container of Jevity 1.2 instead of the 250 mL that was ordered by the physician. Finding include: From 8/5/24 through 8/7/24, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, dementia, adult failure to thrive, dysphagia (difficulty swallowing), and encounter for attention to gastrostomy tube (a medical device used to provide nutrition). R7 had a MIC-KEY tube (an external feeding tube with a button that sits at the level of the skin) through which R7 received nutrition. R7 did not take food or liquid by mouth. R7's medical record contained an order to administer a bolus (single dose given at one time) of 250 mL of Jevity 1.2 around mealtime and evening. On 8/6/24 at 12:07 PM, Surveyor observed LPN-D administer R7 a 237 mL container of Jevity 1.2. On 8/6/24 at 1:45 PM, Surveyor interviewed LPN-D who confirmed R7's order stated to give 250 mL of Jevity 1.2. LPN-D confirmed LPN-D administered 237 mL of Jevity 1.2 which was not in accordance with R7's order. On 8/6/24 at 1:53 PM, Surveyor interviewed Registered Dietician (RD)-E who also confirmed R7 had an order for 250 mL of Jevity 1.2. An Annual Nutrition Assessment for R7, completed by RD-E and dated 12/12/23, indicated R7 received 250 mL of Jevity 1.2 four times daily. RD-E confirmed the container of Jevity 1.2 administered to R7 was 237 mL instead of 250 mL.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R20) of 1 sampled resident received the appropriate care and services to prevent urinary tract infections (UTIs). Staff did not ensure R20 received catheter care in a manner that decreased the risk of infection. Findings include: The facility's Catheter Care, Urinary policy, last reviewed 1/1/24, indicates: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .19. Ensure collection bag is kept below the level of the bladder and that bag and tubing is off the floor . From 8/5/24 to 8/7/24, Surveyor reviewed R20's medical record. R20 had diagnoses including intestinal infectious diseases (gastroenteritis and colitis), neuromuscular dysfunction of bladder with indwelling medical device, calculus in bladder, overactive bladder, and paraplegia. R20's Minimum Data Set (MDS) assessment, dated 6/21/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R20 had intact cognition. R20's plan of care contained interventions to report UTI symptoms and care for R20's Foley catheter per facility protocol. On 8/6/24 at 7:59 AM, Surveyor observed Certified Nursing Assistant (CNA)-I enter R20's room to check R20's catheter. Surveyor noted R20 was in bed and R20's catheter tubing and drainage bag was on the floor under R20's bed. CNA-I noted the R20's catheter bag was empty, stated to Surveyor that care did not need to be performed, and began to leave R20's room. Before CNA-I left the room, Surveyor interviewed CNA-I who confirmed R20's catheter bag should be below the level of the bladder and not in direct contact with the floor. CNA-I left R20's room and did not place R20's catheter bag in a basin, hang the catheter bag on the side of R20's bed below the level of R20's bladder, or remove the catheter bag from the floor. Beginning at 8:04 AM on 8/6/24, Surveyor conducted a continuous observation of R20's room. Nursing staff delivered R20's breakfast tray at 8:11 AM and exited R20's room at 8:12 AM. At 8:12 AM, R20's catheter tubing and drainage bag were still on the floor under R20's bed. On 8/6/24 at 9:46 AM, Surveyor interviewed R20 who stated one of the nurses came in just a minute or so ago and moved R20's catheter bag. R20 stated R20 believed the catheter bag was put in a wash tub because R20 observed nursing staff place a wash tub on the floor. On 8/6/24 at 10:31 AM, Surveyor interviewed Director of Nursing (DON)-B who stated staff should hang a resident's catheter bag from the resident's bed or wheelchair or put the bag in a basin on the floor. DON-B confirmed it was not an acceptable practice to have a resident's catheter tubing and drainage bag in direct contact with the floor.

Based on staff interview and record review, the facility did not notify the State Long Term Care Ombudsman of hospital transfers for 2 Residents (R) (R22 and R43) of 4 residents reviewed for hospitalization . R22 was transferred to the hospital on 5/13/24 and 7/13/24. The State Long Term Care Ombudsman was not provided with written notice of the transfers. R43 was transferred to the hospital on 7/10/24. The State Long Term Care Ombudsman was not provided with written notice of the transfer. Findings include: The facility's Transfer or Discharge Documentation document, revised July 26, 2021, indicates: .4. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, the facility will implement the following procedures and document in the medical record: .G. Notify the representative or other family member of the transfer and behold .I. Others will be notified as appropriate or necessary . 1. From 8/5/24 to 8/7/24 Surveyor reviewed R22's medical record which indicated R22 was transferred to the hospital on 5/13/24 and 7/13/24 for shortness of breath. R22's medical record did not include a copies of the transfer notices provided to the State Long Term Care Ombudsman. On 8/6/24, Surveyor requested copies of the written transfer notices from Director of Nursing (DON)-B. 2. From 8/5/24 to 8/7/24, Surveyor reviewed R43's medical record which indicated R43 was transferred to the hospital on 7/10/24 to rule out cardiac issues due to perspiration and pain radiating from R43's arm to chest. R43's medical record did not include a copy of the transfer notice provided to the State Long Term Care Ombudsman. On 8/6/24, Surveyor requested a copy of the written transfer notice from DON-B. On 8/6/24 at 11:34 AM, Surveyor received a Notice of Transfer and Discharge form for R22 and R43 from Social Worker (SW)-H. Surveyor interviewed SW-H who stated the facility did not have documentation of notification to the Ombudsman because the facility only notified the Ombudsman if the discharge was disputed or a 30 day notice was given to the resident. SW-H stated Nursing Home Administrator (NHA)-A completed the transfers and discharges and notified the Ombudsman if necessary. SW-H stated SW-H would speak with NHA-A and provide any documentation to the Ombudsman to Surveyor. On 8/6/24 at 1:52 PM, SW-H approached Surveyor and stated the facility did not have consistent communication with the Ombudsman and only notified the Ombudsman if there was a disputed transfer or a 30 day discharge notice was given. SW-H provided Surveyor with an email from the Ombudsman to NHA-A, dated 7/19/21, that indicated notification of unplanned discharges should to be sent to the Ombudsman. The email indicated most facilities send an end-of-the-month transfer summary to the Ombudsman and provide same day notification when a 30 day notice is issued. The email stated the facility should keep all notifications in case a transfer or discharge is disputed and a resident or family representative requires assistance with an appeal. The email indicated the Ombudsman should also have information regarding the transfers and discharges. On 8/7/24 at 9:12 AM, Surveyor interviewed NHA-A who stated 30 day notices are sent to the Ombudsman but hospital transfer and discharge notifications are only sent to the Ombudsman if they are disputed. NHA-A stated NHA-A believed, despite the email communication from the Ombudsman, that NHA-A was correctly following the requirements.

Based on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R29) of 2 residents reviewed for pressure injuries received care and treatment to prevent the development of pressure injuries. R29 was at risk for the development of pressure injuries. R29's plan of care contained an intervention for a cushion in R29's recliner. R29 was observed without a cushion in R29's recliner. Findings include: The facility's Prevention of Pressure Injuries policy, last reviewed 1/1/23, contained the following information: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. The facility's Support Surface Guidelines policy, last reviewed 1/1/23, contained the following information: Redistribution support surfaces are to promote comfort for all bed or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. R29 was admitted to the facility on [DATE] with diagnoses that included muscle weakness, reduced mobility, dementia, and encounter for palliative care. R29's Minimum Data Set (MDS) assessment, dated 4/7/23, contained a Brief interview for Mental Status (BIMS) score of 7 out of 15 which indicated R29 had severe cognitive impairment. R29 required staff assistance for transfers and repositioning. The MDS indicated R29 was at risk for pressure injury development and had a pressure reducing device for chair. R29's Braden Scale for Predicting Pressure Sore Risk document, dated 4/7/23, indicated R29 was at risk for pressure injury development. R29's plan of care included an intervention, dated 5/23/23, for an air cushion to recliner. On 7/10/23 at 10:07 AM, Surveyor observed R29 and R29's spouse in R29's room. R29 was sitting in a recliner and stated to Surveyor that R29 had open areas on the ass. Surveyor asked R29 and R29's spouse if there was a cushion in R29's recliner. R29's spouse stated, They usually have one in the chair. Surveyor verified R29 did not have a cushion in R29's recliner. On 7/11/23 at 1:51 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-E who indicated R29 previously had excoriated skin on the buttocks that was moisture-associated skin damage and was healed as of 6/7/23. ADON-E indicated R29 had interventions that included a cushion to the chair. On 7/11/23 at 1:57 PM, Surveyor observed R29 in a recliner without a cushion in R29's room. On 7/11/23 at 1:59 PM, Surveyor and ADON-E entered R29's room. ADON-E verified there wasn't a cushion in R29's recliner and checked R29's care plan and orders. On 7/11/23 at 2:08 PM, ADON-E indicated to Surveyor that R29 should have a cushion in the chair and that the cushion was in R29's closet or wheelchair. ADON-E stated ADON-E told staff to put the cushion in R29's recliner. On 7/12/23 at 9:25 AM, Surveyor observed R29's buttocks with Certified Nursing Assistant (CNA)-F and CNA-G. Surveyor noted R29 had minimal excoriation to the bilateral inner buttocks. CNA-F and CNA-G stated R29's cushion should be in the chair when R29 was in the chair.

Based on staff and resident interview, and record review, the facility did not ensure an individualized comprehensive care plan was developed for 1 Resident (R) (R14) of 19 sampled residents. R14 did not have an individualized care plan that included activities to meet R14's interests and support R14's physical, mental, and psychosocial well-being. Findings include: On 7/10/23 at 11:44 AM, Surveyor interviewed R14 who was upset and stated, I'm bored. I like to go outside. Sometimes I go to activities, but I can't hear, so sometimes I miss out. I live in the apartments over there where my friends are. I want to go home. On 7/10/23, Surveyor reviewed R14's medical record. R14 had diagnoses that included dementia, adult failure to thrive, hearing loss, and generalized weakness with abnormalities of gait and mobility. R14 had an activated Power of Attorney for Health Care (POAHC) who made decisions regarding R14's medical care. R14's MDS assessment, dated 6/19/23, indicated R14's ability to hear was moderate difficulty-speaker has to increase volume and speak distinctly. R14 was non-ambulatory and required extensive assistance of staff for transfers and locomotion off the unit. The MDS indicated it was very important for R14 to do R14's favorite activities and somewhat important to go outside to get fresh air when the weather was good. Surveyor reviewed the Activity Attendance Observation Log which did not include going outside, but included the following activities that R14 was offered: ~7/3/23: Lutheran Service ~7/4/23 PM: Arts and crafts ~7/5/23: Refused sugar cookies ~7/5/23: Root beer floats ~7/5/23 1-1 ~7/10/23: Lutheran Service On 7/12/23 at 9:54 AM, Surveyor interviewed Activities Director (AD)-C who completed MDS sections B (hearing and vision assessment) and F (likes and dislikes and spiritual care assessment) for R14. AD-C indicated when R14 was admitted to the facility from the adjacent Assisted Living facility, R14's therapy was initially heavy, but is now less. AD-C stated therapy staff contacted AD-C to ask if R14 can be more involved in activities. AD-C stated R14 likes to go outside, play Bingo, and participate in small group activities. AD-C verified R14 went outside with an activity aide on 7/11/23 and stated Certified Nursing Assistants (CNAs) take residents outside if they have free time. AD-C verified R14 is hard of hearing and indicated activity aides get close to R14's ear and verbally offer activities. AD-C also stated residents are given a monthly activity calendar to keep in their room and activity aides go over what activities are offered each day. AD-C verified R14's plan of care did not address R14's preferred activities or how to approach R14 (due to R14's hearing loss) to offer activities. AD-C agreed activities should be included in R14's plan of care, including an intervention to go outside.

Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R17) of 5 sampled residents was monitored for adverse consequences of an antipsychotic medication. R17 was prescribed risperidone (an antipsychotic medication) for dementia. R17 did not have a care plan that addressed antipsychotic medication use and contained monitoring interventions for adverse consequences of the medication. Findings include: R17 was admitted to the facility on [DATE] and had diagnoses that included vascular dementia with anxiety and anxiety disorder. R17 was prescribed risperidone which contains a black box warning (the Federal Food and Drug Administration's (FDA's) most stringent warning that alerts the public and health care providers to serious side effects, such as injury or death). Between 7/10/23 and 7/12/23, Surveyor reviewed R17's medical record which indicated R17 was prescribed antipsychotic medication on 2 occasions since admission on 3/6/23: ~quetiapine (an antipsychotic medication) from 3/6/23 until 3/12/23 ~risperidone from 4/17/23 through the date of survey Surveyor noted R17 did not have a care plan that addressed antipsychotic medication use and contained monitoring interventions for adverse consequences. On 7/12/23 at 8:15 AM, Director of Nursing (DON)-B verified to Surveyor that R17's plan of care did not include monitoring for adverse consequences of risperidone. On 7/12/23 at 1:10 PM, Surveyor interviewed DON-B who stated DON-B expected residents to have care plans and monitoring interventions in place for antipsychotic medication use. DON-B indicated this was an issue when DON-B started the DON role and DON-B was training staff to recognize antipsychotic medications and ensure monitoring interventions and care plans were initiated. DON-B indicated DON-B completed an audit, but thought R17 started risperidone after the audit was completed.

Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R17) of 5 sampled residents was monitored for adverse consequences for a high-risk medication. R17 was prescribed furosemide (a diuretic medication). R17's plan of care did not contain monitoring for adverse consequences of furosemide. Findings include: R17 was admitted to the facility on [DATE] and had diagnoses that that included congestive heart failure, dehydration, and hypertension. R17 was prescribed furosemide (used to help treat fluid retention (edema)and swelling caused by congestive heart failure, liver disease, kidney disease, or other medical conditions. Diuretic medications can cause dehydration.) Between 7/10/23 and 7/12/23, Surveyor reviewed R17's medical record and noted R17 was administered furosemide during the following time frames: ~From 3/6/23 through 3/30/23 ~From 5/25/23 through 5/27/23 ~From 6/21/23 through the time of survey. A provider note, 6/2/23, indicated R17 was seen for left leg cellulitis. The note indicated: Not currently on any diuretics, but it appears R17 was on furosemide 20 mg (milligrams) daily for 3 days (ordered 5/24/23 to 5/27/23) and previously chronic furosemide was discontinued due to labile blood pressures. Surveyor noted R17 did not have a care plan that addressed diuretic use and contained monitoring interventions for adverse consequences. On 7/12/23 at 8:15 AM, Director of Nursing (DON)-B verified to Surveyor that R17's plan of care did not include monitoring for adverse consequences of furosemide. On 7/12/23 at 1:10 PM, Surveyor interviewed DON-B who stated DON-B expected residents to have care plans and monitoring interventions for high risk medications. DON-B indicated this was an issue when DON-B started the DON role and DON-B was training staff to recognize high risk medications and to ensure monitoring interventions and care plans were initiated. DON-B indicated DON-B completed an audit, but thought R17 started furosemide after the audit was completed.

Based on interview and record review the facility did not provide the necessary respiratory care and services consistent with current professional standards of practice for 1 resident (R) (R2) of 2 residents reviewed for oxygen use. R2 record reviewed documented R2 was using oxygen. R2 did not have a physician's order for use, a care plan in place, or cleaning schedule for the oxygen tubing. Findings include: The facility provided a policy titled; Oxygen Administration dated 6/1/21. Under preparation it stated: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident. 3. Assemble the equipment and supplies as needed. R2 was admitted to the facility on [DATE] with related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 had a Brief Interview of Mental Status score of 8/15 which indicated moderate impaired cognition. R2 Power of Attorney for Healthcare was activated. On 6/29/22, the Surveyor reviewed R2's medical record and did not observe a physician's order, care plan, or how the facility was monitoring and ensuring the oxygen tubing was changed. Surveyor did note that on R2's hospital discharge orders dated 5/21/22 indicated an order stating: Oxygen per nasal cannula as needed for dyspnea; 4 Lpm (liters per minute) for mild, 5 Lpm for moderate, 6 Lpm for severe. Patient (R2) currently using: 6L On 6/29/22 at 2:46 PM, the Surveyor interviewed Director of Nursing (DON)-B who confirmed there was no physician's order, care plan or how the facility was monitoring and ensuring tubing was changed for R2. DON-B indicated the expectation is there should be a physician's order, care plan and how the facility was monitoring and ensuring the tubing was changed.

Based on record review and staff interview, the facility did not promptly notify the physician or the Resident Representative when a change in condition occurred for 1 Resident (R) (R2) of 3 residents reviewed. R2 fell on [DATE] and 6/13/22. The facility did not notify R2's Physician or Resident Representative on 5/22/22 and 6/13/22. Findings include: R2 was admitted to the facility on [DATE] and had related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 had a Brief Interview of Mental Status score of 8/15 which indicated moderate impaired cognition. R2 Power of Attorney for Healthcare was activated. On 6/29/22, The Surveyor reviewed R2's medical record which contained a progress noted, dated 5/22/22 at 2:02 PM, that stated, Resident (R2) stated (R2) fell on the floor when attempting to self-transfer from hospital bed to wheelchair. Resident (R2) also claims (R2) was able to self-transfer off the floor and back to into bed without any assistance. No witnesses were present at time of incident. Head-to-toe assessment was completed and no apparent injuries noted. Resident (R2) appears to be alert and oriented with episodes of confusion noted. Per Family Member (FM)-C is requesting fall mats. This writer will continue to monitor, provide comfort and safety measures. The Surveyor reviewed Hospice notes, dated 5/22/22 at 2:00 PM, that stated, Patient (R2) reports fall this morning no signs or symptoms of injury. The Surveyor could not find any documentation indicating R2's Physician or R2's Resident Representative was updated after the fall. On 6/29/22, The Surveyor reviewed facility provided Event Report for R2 fall, dated 6/13/22, which contained a Notification section which indicated R2's Attending Faxed: No, Physician Notified: No, Resident Representative Notified: No. On 6/29/22 at 2:19 PM, The Surveyor interviewed Anonymous Family Member (AFM)-D regarding R2's fall that occurred on 5/22/22. AFM-D verified was not notified by the facility staff. AFM-D verified another family member told AFM-D about the fall. AFM-D confirmed after they found out about the fall from another family member AFM-D went to facility staff inquiring as to what occurred and then AFM-D called hospice to check on R2. On 6/29/22 at 2:46 PM, The Surveyor interviewed Director of Nursing (DON)-B regarding R2's falls on 5/22/22 and 6/13/22. DON-B verified no documentation regarding R2's Physician and Resident Representative being updated regarding R2's falls on 5/22/22 and 6/13/22. DON-B discussed would expect the Physician and Resident Representative to be updated after a fall.

Based on interviews and record review, the facility did not test residents for COVID-19 as required during an outbreak which included testing frequency and testing of asymptomatic individuals during an outbreak. This had the potential to affect all 46 residents residing in the facility and all staff. The facility did not test all residents every three to seven days from the date of the most recent positive COVID-19 result on 7/12/21, during an active COVID-19 outbreak in the facility. Findings Include: CMS (Centers for Medicare and Medicaid Services) Memo QSO-20-38-NH (Nursing Home)with a revision date of 4/27/21, provides guidance for COVID-19 testing of nursing home staff and residents stated, To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS (Health and Human Services) Secretary .For outbreak testing, all staff and residents should be tested , and all staff that tested negative should be retested every 3 to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of 14 days since the most recent positive result An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. On 8/4/21, the Surveyor reviewed the facility's policy and procedures related to COVID-19. The facility policy did not document requirements related to COVID-19 testing and frequency of staff and residents during outbreak status. On 8/4/21, the Surveyor reviewed the facility's staff COVID-19 timeline. The timeline documented on 7/12/21, a staff member had tested positive for COVID-19. On 8/4/21, the Surveyor reviewed COVID-19 testing documentation provided by Assisted Director of Nursing (ADON)-C who is also responsible for the facility's infection control program. The documents indicated on 7/13/21 and 7/21/21 all staff were tested for COVID-19 and on 7/12/21 and 7/20/21 all residents were tested for COVID-19. No additional COVID-19 testing has been conducted in the facility. On 8/4/21 at 12:54 PM, the Surveyor interviewed ADON-C who stated when the facility is in an outbreak the facility would conduct COVID-19 testing according to the CMS Memo QSO-20-38-NH. ADON-C confirmed to the Surveyor a staff member tested positive for COVID-19, which meant the facility was in outbreak status on 7/12/21. ADON-C informed the Surveyor the facility did not follow CMS Memo QSO-20-38-NH requirements and did not test staff or residents for a period of 14 days since the most recent positive result.

Based on record review and staff interview, the facility did not maintain an Infection Prevention and Control Program (IPCP) to recognize and control the onset and spread of infection for 3 Residents (R) (R12, R23, and R31) of 46 residents in the facility. This had the potential to affect all residents in the facility, Resident (R) R12 and R23 had signs and symptoms of potential infection and were not included on the facility line list. The facility's infection surveillance program did not include all residents symptomatic of an infection, as only residents that were prescribed medication(s) to treat an infection were included on the list. R31 had symptoms of respiratory infection and a COVID-19 test was ordered on 8/2/21; however, quarantine and droplet precautions (used to prevent the spread of infection passed through coughing, sneezing or talking) were not started until the following day. Findings: 1. The facility policy dated 4/13/21, entitled, Coronavirus Disease (COVID-19) will be identified and isolated to help control the spread of infection to other residents, staff and visitors stated: If a resident has signs or symptoms that suggest a developing respiratory infection or COVID-19: a. The charge nurse is notified immediately b. The resident is assessed by a licensed nurse c. Assessment information is reported to the Infection Preventionist d. The Infection Preventionist notified the local health department of any new suspected cases of COVID-19 and requests testing, and e. Resident information is added to the Respiratory Surveillance Line list and included in the resident impact data for reporting to the Center of Disease Control (CDC). On 8/2/21-8/4/21 the Surveyor reviewed R12's medical record. On 6/10/21 at 1:50 PM, R12's progress notes documented, Resident had hoarse voice this am due to coughing during night. No fever noted. Quick COVID test negative. R12 was not included on the facility's Respiratory Surveillance Line list. On 8/2/21-8/4/21 the Surveyor reviewed R23's medical record. On 6/24/21 at 10:55 AM, R23's progress notes documented, Obtained COVID test - will send to lab. On 6/24/21 at 1:39 PM, R23's progress notes documented, Coughing and sneezing throughout shift. No wheezing noted. Oxygen remain on due to when removing oxygen would go into low 80's R23 was not included on the facility's Respiratory Surveillance Line list. 2. On 8/2/21-8/4/21 the Surveyor reviewed the facility's infection control program including the facility overall surveillance of potential infection. The facility's infection line list only included residents who were prescribed antibiotics and did not include signs and symptoms of potential infections. On 8/3/21 at 4:11 PM, the Surveyor interviewed Assistant Director of Nursing (ADON)-C, who is responsible for the facility's infection control program. ADON-C indicated residents that had symptoms of an infection, that were not prescribed a medication to treat their infection would not be included on the facility's surveillance data, thus not included in the information used to help determine clusters, trends and/or outbreaks, and would also not be included in the facility's rates of infection. ADON-C indicated a resident not being treated with a medication to treat their infection is not considered an infection and the resident is not maintained on any type of surveillance log by the facility. ADON-C stated the facility would have to look through each resident's medical record to identify an illness or potential outbreak. ADON-C verified the facility would not be able to identify trends and outbreaks based on their current system of infection surveillance/monitoring. ADON-C informed the Surveyor the facility should start documenting when residents present with symptoms and what the facility did, like what type of precautions they were put on, and when. ADON-C stated the facility is currently exploring forms to use for monitoring residents who present with signs and symptoms of illness not just the residents on antibiotics and residents with COVID-19. 3. Center for Disease Control (CDC) guidelines updated 2/23/21 state, healthcare providers who enter the room of a patient with suspected or confirmed COVID-19 infection should adhere to standard precautions (practices that protect healthcare providers) and use a N95 respirator (a filtering facepiece) or equivalent, gown, gloves and eye protection. On 8/2/21 at 10:15 AM, the Surveyor interviewed R31. R31 stated R31 was hoping to get rid of the cough R31 had. The Surveyor observed an incentive spirometry device (a medical device used to help improve the functioning of lungs) at R31's bedside. R31 stated, They (staff) said I should use that for my cough. The Surveyor observed R31 cough during the interview. On 8/3/21 at 11:30 AM, the Surveyor observed an isolation cart outside of R31's room door which contained personal protective equipment (PPE) (e.g. gloves, gown, goggles) - this cart was not present the day prior. There was not signage on R31's door indicating what type of precautions are to be followed when entering R31's room. The Surveyor interviewed Certified Nursing Assistant (CNA)-D as to the reason for the infection prevention cart. CNA-D stated that R31 was awaiting a COVID-19 test due to cough and wheezing which started yesterday. On 8/3/21 at 11:40 AM, the Surveyor conducted a review of R31's electronic health record. A progress note dated 8/2/21 at 4:21 PM by Licensed Practicing Nurse (LPN)-E read as follows: Writer advised by social services that resident was wheezing as R31 conversed. Audible wheezing on exhalation was heard without auscultation (listening to sounds from the lungs with a stethoscope). BLL (bilateral lower lobes) (part of the lung) are diminished and wheezing, upper lung areas are wheezing on exhalation. Assisted resident with incentive spirometer. Vital Signs: remains afebrile (without fever), oxygen 96% on room air. Additional progress notes dated 8/2/21 by LPN-E: 8:33 PM Received call from doctor, orders: STAT chest X-ray and lab work 9:03 PM Writer updated resident's daughter on ordered labs and chest X-ray. 10:50 PM Ordered labs were drawn by writer at 10:15 PM. Resident tolerated lab draws well. On 8/3/12 at 11:57 AM, the Surveyor again noted there to be no signage as to what type of precautions should be followed outside of R31's room door. The isolation cart remained outside of R31's room. On 8/3/21 at 12:28 PM, the Surveyor interviewed Director of Nursing (DON)-B. DON-B stated R31 is now off isolation; DON-B explained that R31 had been on isolation due to a pending COVID-19 test, which had now returned as negative. DON- B stated the isolation was precautionary. DON-B was not certain when isolation precautions were started. On 8/4/21 at 9:33 AM, DON-B provided Surveyor with documentation of education to facility staff dated 10/09/20 which read: Any resident who shows any COVID symptoms needs to be placed on isolation immediately and all PPE, including a N95 mask needs to be worn until it is confirmed with a rapid COVID-19 swab at the lab whether the resident has COVID. If they have COVID, they need to be moved to the COVID unit. If they do not, they still need to remain on droplet precautions until cleared by myself to come off of precautions. DON-B also provided documentation of education to facility staff dated 8/3/21 3:11 PM which read: It is absolutely imperative that if someone is having new or worsening respiratory symptoms that they are place don precautions immediately pending a COVID swab. Please also note that pending the COVID swab, all caregivers must wear a N95 into that resident's room. On 8/4/21 at 3:25 PM, DON-B reported to the Surveyor that after speaking with LPN-E, infection prevention protocols (isolation and implementation of PPE) were not put in place for R31 until 7:30 AM the day following discovery of symptoms (8/3). DON-B stated the expectation was to have placed these infection prevention measures in place the day prior (8/2) when symptoms were reported. On 8/4/21 at 3:37 PM, the Surveyor interviewed LPN-D. LPN-D stated, It did not dawn on me to start precautions at the time.

Based on interviews and record review, the facility did not ensure a process was defined in which to dispose of controlled drugs (a medication that is likely to be abused) in sufficient detail to enable an accurate reconciliation. This impacted one Resident (R) (R27), and had the potential to effect multiple residents. R27's medical record included four progress notes indicating R27's [MEDICATION(S)] patch was not on R27's body at the time of placement check (occurred every shift to verify placement of the [MEDICATION(S)] patch). When staff were interviewed regarding the destruction of [MEDICATION(S)] patches after the patch is taken off a resident or found off the body, the staff did not have a consistent standard to reference. Findings: According to https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-02.pdf: B. [MEDICATION(S)] Patches [MEDICATION(S)] patches are a controlled substance commonly used in nursing homes for pain medication. These patches present a unique situation given the multiple boxed warnings, the potential for abuse, misuse and diversion, and the substantial amount of [MEDICATION(S)] remaining in the patch after use. The facility's policies must address safe and secure storage, limited access and reconciliation of controlled substances in order to minimize loss or diversion, and provide for safe handling, distribution and disposition of the medications . This unique delivery system, however, is not impervious (not allowing something through) to diversion, even after the [MEDICATION(S)] patch has been used, removed and/or disposed. One study determined that even after three days of use, 28 to 84.4% of the original [MEDICATION(S)] dose was still present in the patch. The study noted that the dose remaining in the patch was within the limits of a lethal [MEDICATION(S)] dose. The remaining [MEDICATION(S)] in a used patch is a potential vehicle of abuse and accidental overdose and warrants implementation of adequate disposal policies. [MEDICATION(S)] products contain several boxed warnings related to potential abuse, misuse, and diversion, and specifically, the contraindication of [MEDICATION(S)] patch use in individuals who are not opioid tolerant. Staff should dispose of [MEDICATION(S)] patches in the same manner as wasting of any other controlled substances, particularly because the active ingredient is still accessible. Wasting must involve a secure and safe method, so diversion and/or accidental exposure are minimized. On 8/04/21 at 9:42 AM, Director of Nursing (DON)-B provided Surveyor the facility policy titled Controlled Substances. The policy states: 11. Upon Disposition: b. Medications that are opened and subsequently not given (refused or only partly administered) are destroyed. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet. The policy did not include where to waste or dispose of controlled substances and did not provide guidance for disposition of [MEDICATION(S)] patches. On 8/04/21 at 9:42 AM, Surveyor interviewed DON-B. DON-B stated DON-B was unaware of three of the four situations that were documented in R27's medical record and would get back to Surveyor regarding the situations. Surveyor provided the following dates where R27's [MEDICATION(S)] patch was not found on R27 at the time of placement check and did not include if the patch was ever found: 2/9/21, 5/12/21, 6/26/21, and 7/4/21. On 8/4/21 at 11:14 AM, Surveyor interviewed DON-B. DON-B who provided information on each occurrence: On 2/9/21 the nurse stated the patch was on R27's undergarment. No documentation of the disposition of the patch was provided. On 5/12/21 the progress notes stated the [MEDICATION(S)] patch was not found on R27 and a new patch was put on R27. This was the occurrence DON-B was aware of and investigated. The [MEDICATION(S)] patch was not found. On 6/26/21 the progress note stated a CNA (Certified Nursing Assistant) threw the patch in garbage because it fell off. DON-B stated the CNA did not report it because it was found. DON-B does not know how staff destroyed the old patch and the progress note does not provide information stating the patch was found. On 7/4/21 the progress note stated the [MEDICATION(S)] patch was not found and laundry was notified. DON-B stated staff reported to DON-B the patch was found by laundry. No documentation was provided how or by who the patch was disposed of. On 8/4/21 at 11:14 AM, Surveyor asked DON-B where [MEDICATION(S)] patches are disposed. DON-B stated staff put them in the sharps container, but DON-B stated DON-B will have to verify. On 8/4/21 at 12:16 PM, Surveyor interviewed DON-B. DON-B stated DON-B asked a couple nurses and the nurses either dispose of [MEDICATION(S)] patches in the sharps container or drug buster (container with undesirable solution to prevent diversion) depending on the nurse.

Based on observation, interview and record review, the facility did not ensure Activities of Daily Living (ADLs) consistent with the resident's needs and choices were provided for 1 resident (R) (R38) of 14 residents reviewed. R38 had difficulty hearing conversations. A hearing exam and hearing aid fitting was conducted on 4/28/21 with R38; however, the facility did not ensure appropriate documents were sent to the hearing provider. R38 had not received hearing aids as of 8/3/21. Findings: Alzheimer's Association publication dated 7/14/19 stated: Two studies reported at the Alzheimer's Association International Conference (AAIC) 2019 found that experiencing multiple sensory impairments, such as vision and hearing problems, are associated with an increased risk of developing dementia in older adults. Research from the University of Washington School of Public Health showed that impairment of either vision or hearing increases the risk of developing dementia, and that impairment in both senses further increases those odds. R38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On review of R38's medical record, R38's BIMS (brief interview for mental status) (a screen used to assist with identifying a resident's current cognition) dated 1/13/21 score was 13 out of 15, indicating intact cognitive response. R38's BIMS conducted on 7/16/21 scored 12 out of 15, indicating moderately impaired cognition. On 8/2/21 at 11:07 AM, the Surveyor attempted to interview R38. R38 had difficulty hearing the Surveyor and referred the questions to R38's family member (FM)-G who was in the room at the time. The Surveyor noted that R38 was not wearing hearing aids. On 8/2/21 at 1:08 PM, the Surveyor conducted further review of R38's health record. R38's medical record did not include a Power of Attorney for Health Care (POA-HC) document. R38's care plan read: I may not always understand conversation related to HOH (hard of hearing). Minimum Data Set (MDS) assessments (determines resident's capabilities and helps identify health care needs) dated 7/16/21, 4/15/21 and 1/13/21 indicated R38 had moderate difficulty with hearing. Progress note dated 1/12/21 4:25 PM by Registered Dietician read: R38 could not answer additional interview questions, therefore deferred (postponed) due to resident HOH. Progress note dated 5/18/2110:29 AM by previous Social Worker (SW) read: Hearing aid update: [FM-G] here to inquire about paperwork received from hearing provider back in April. Wondering where process was at and was unable to reach Audiologist to inquire. Writer placed a call and left message requesting to be updated on progress of hearing aid. Waiting for a call back. Progress note of 5/20/21 8:21 AM by previous SW read: Update: Call placed to hearing provider this week to inquire about status of hearing aids. Have not received a call back from company. [FM-G] updated this morning, instructed will call [FM-G] with an update as soon as company calls writer. Subsequent progress note documentation dated 7/21/21 8:36 AM read: Reached out to provider who came to fit resident for hearing aids, as still have not received them. On 8/3/21 at 5:12 PM, the Surveyor interviewed SW-F. SW-F confirmed that there was not a POA-HC document on file for R38, that R38 was able to make decisions on own and also had FM-G help R38 make some decisions. SW-F reported speaking with FM-G on 7/23/21 at which time FM-G had given up on getting the hearing aid with the original hearing provider and was planning on trying to find somewhere else on FM-G's own to get R38 a hearing aid. SW-F was not certain of the original hearing exam date, noting SW-F started working at the facility about one month ago. SW-F reported that there was a form that needed to be completed by the FM-G and it was SW-F's understanding that form had not been filled out which is what caused the delay with receiving the hearing aid. The Surveyor asked SW-F if another specific named health care provider for hearing services (HP)-I came to the facility for hearing services for residents and SW-F replied, Yes, I did not even think of that, I will offer that to FM-G. On 8/4/21 at 1:08 PM, the Surveyor interviewed R38. R38 had difficulty hearing the Surveyor; however, with raising the volume of voice and speaking slow and clear and repeating self, communication was accomplished. R38 stated having a hearing test and was fitted for a hearing aid at the facility several months ago. R38 confirmed it is hard to hear and explained it is even harder to hear when people have masks on. R38 reported having had hearing aids a while ago when living at home (prior to residing in the facility), but the hearing aids broke. When asked if R38 would like hearing aids, R38 stated, It would be nice to hear. On 8/4/21 at 1:14 PM, the Surveyor called R38's insurance/health care service group (HS)-H who confirmed a hearing exam was conducted with R38 at the facility on 4/28/21 and that the hearing aids had not been ordered yet. HS-H further explained that in May, 2021, HS-H reached out to the facility requesting a form which the facility sent back; however, the signature on the form was not R38's, so HS-H called the POA (FM-G), who signed the form. HS-H indicated FM-G nor the facility provided proof of documentation that [FM-G] was the activated POA-HC. Surveyor explained to HS-H that there was not an activated POA-HC; HS-H representative then explained that all HS-H would need was R38's signature on the form and the hearing aids could be ordered as soon a HS-H received that form. HS-H stated all the facility would need to do is contact HS-H and a new form would be provided for R38 to sign. The representative confirmed that HS-H also would cover the cost of HP-I if R38 chose to utilize HP-I's services as HP-I was considered within network as well.

Based on interviews and record review, the facility did not thoroughly investigate an allegation of misappropriation of narcotic medications from a contingency box and an allegation of abuse having the potential to effect multiple residents. On 11/9/2020, the facility discovered missing narcotic medications (medications that are prescription only and have addictive properties and require accurate and thorough accountability) from the contingency box. The facility's investigation did not include statements from staff or residents, narcotic or pain audit documentation, or evidence supporting the staff member accused was the perpetrator. R24 reported an abuse concerns and a thoroughly investigation was not conducted by the facility to ensure abuse/neglect did not occur. Findings: 1. On 11/9/2020, the DON (Director of Nursing)-B was alerted by named pharmacy that six tablets of [MEDICATION(S)]/acetaminophen 10/325 mg (milligrams) and ten tablets of Oxycodone/acetaminophen 5/325 mg were missing from the facility's narcotic contingency medication box (a locked box that is provided to the facility from named pharmacy stocked with narcotic medication in the event a resident needs a specific medication before the pharmacy is able to deliver to the facility). The narcotic contingency box was picked up by named pharmacy on 11/5/2020. DON-B provided Surveyor a copy of the facility investigation. The investigation stated writer (DON-B) asked named pharmacy to review the tape of the packing procedure of the contingency box and of the room where the narcotic contingency box sat prior to being verified on 11/9/2020. No further information was provided related to the outcome of that request. Investigation stated DON-B interviewed all nurses that worked during the time frame the narcotics allegedly went missing. The investigation did not include the interviews or any statements from staff. On 8/4/2021 at 9:42 AM, Surveyor interviewed DON-B who stated every shift the nurse performs a pain assessment on residents and if there was a concern regarding changes in pain trends, that would alert staff to investigate. DON-B stated there were no indications of increase in pain that alerted staff, so the facility did not further investigate. DON-B stated DON-B reviews all narcotic medication logs for discrepancies and that the logs did not cause suspicion of diversion. No further investigation or audit was performed to ensure narcotic medications documented as administered accurately reflected what was provided to residents. The facility investigation did not include resident interviews. The facility investigation did not include a statement from the accused staff member (no longer employed by the facility as of 11/15/2020). The facility investigation did not include evidence directly linking accused staff member to the missing narcotic medications from the narcotic contingency box. No additional steps were documented as part of the investigation to ensure resident narcotic medication was administered appropriately to rule out potential additional narcotic medication diversion. 2. On 8/3/21, the Surveyor reviewed the facility's grievance file which included a grievance dated 7/8/21 which documented: R24 reported to NOC (3rd shift) staff two aids put R24 on the bedpan at 4:00 AM, and did not return to take R24 off bedpan. The nurse found R24 at 5:45 AM, when the nurse came in to give R24 medication. CNA noticed when in R24's room R24 did not have R24's call light within reach. The facility's investigation into the incident included a statement from R24 and the staff member who found R24 on the bedpan at 5:45 AM. The facility's investigation did not include interviews from the staff members who were involved in the reported incident. Other residents potentially affected were not interviewed by the facility related to this incident. Additionally, the facility's investigation did not include interviews with any noc (3rd) shift staff who may have had additional knowledge of neglect or cares not being provided for other residents. On 8/4/21 at 1:44 PM the Surveyor interviewed NHA-A regarding the grievance dated 7/8/21 involving R24. NHA-A stated the facility put education out regarding the incident to prevent future occurrences. NHA-A confirmed to the Surveyor the facility did not interview the involved staff member or additional residents or staff members to rule out abuse/neglect concerns.

Based on interview and record review, the facility did not ensure 1 (resident #1) of 9 sampled residents had the necessary advance directive documentation to ensure his life sustaining wishes would be honored. Resident #1 was receiving hospice services and verbalized to staff the desire to receive CPR (CardioPulmonary Resuscitation), a medical intervention used to restore circulatory and/or respiratory function if he became pulseless and non-breathing, if needed. Resident #1 also informed staff the wish to have "one round" of CPR and didn't want any fractured ribs. Staff updated the resident's physician, and updated the medical record to indicate the resident wanted the code status to be a full code, however the facility did not discuss with the resident what the meaning of "one round" of CPR meant. In addition, the facility staff did not investigate if "one round" of CPR was considered to be a standard of practice that the facility could implement. Facility staff did not conduct further discussions with resident #1 or provide guidance to staff to ensure resident #1's life-sustaining choices were carried out as the resident wished. As resident #1's health declined, the facility did not formulate a plan to meet the resident's life-sustaining choices. When resident #1 was found pulseless and breathless, staff did not have clear direction, and in attempts to seek clarification, appropriate CPR procedures were not implemented and were not implemented timely in that staff did not call 911 until 21 minutes later. Additionally, staff did not call the POAHC (Power Of Attorney for Health Care) for guidance regarding the resident's CPR choices. The facility failure to clarify the resident's code status resulted in staff stopping CPR for ,[DATE] minutes, before the POAHC called the facility and directed them to resume life-sustaining measures. The failure of the facility to ensure that Resident #1's wishes were clarified and clearly noted and the failure to implement appropriate measures to ensure that resident's life-sustaining choices were carried out as the resident wished created a finding of immediate jeopardy. The jeopardy began on [DATE] when resident #1's life-sustaining wishes changed and these were not accurately reflected in the medical record. NHA (Nursing Home Administrator)-A was formally notified on [DATE] that an Immediate Jeopardy situation existed. The Immediate Jeopardy was removed on [DATE], however the deficient practice continues at a scope and severity of E (potential for harm that is not immediate jeopardy/pattern) while the facility works to fully implement its action plan. Findings include: The facility's CPR policy dated [DATE] directed staff to call 911 immediately after calling a code for a resident. The discrepancy of when staff were or were not to call 911 for a resident receiving hospice services that requested their CPR status to be a full code was not addressed, leaving staff without clear direction if the resident coded. The facility's contract with the hospice agency, Affinity Visiting Nurses, indicated the facility was to contact hospice immediately if the resident had a change in condition. The hospice after hours contact information form directed staff to "Do NOT call 911" in bold letters. Resident #1's undated face sheet documented that the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's admission MDS (Minimum Data Set) assessment documented the resident's cognition was intact and the resident was his own decision maker. Resident #1's medical record included the following documentation: * [DATE]- staff informed resident #1's physician that the resident was choosing to have CPR, if needed. * [DATE]- the physician's assistant responded to the resident's CPR decision indicating this choice was ill advised, but the resident's code status would be full code. * ,[DATE]- monthly physician's orders [REDACTED]. * ,[DATE]- monthly physician's orders [REDACTED]. Resident #1's medical record indicated the resident's code status did not change throughout the rest of the resident's stay in the facility and the resident remained a full code. The resident had a "Power Of Attorney for Health Care" document completed on [DATE]. The document assigned the resident's daughter to be the POAHC if the resident was no longer able to make health care decisions. Resident #1's Hospice admission progress note documented the resident began receiving hospice care services on [DATE]. Despite the resident's choice to be a full code, the resident's code status was to be DNR (Do Not Resuscitate). Under Wisconsin law, there must be a signed physician's orders [REDACTED]." Hospice documentation did not reflect resident #1's choice to be a "full code." Resident #1's medical record did not include documentation that the facility had obtained a physician's orders [REDACTED]. Resident #1's hospice care plan dated [DATE], indicated the resident was a DNR status and directed staff to "Do not call 911- call hospice first." On [DATE], resident #1's hospice care plan was updated to indicate the resident was a full code in the "Directives" section. However, the "interventions" portion of the hospice care plan indicated the resident's code status was DNR and directed staff to "Do not call 911- call hospice first." Resident #1's medical record did not include a physician's orders [REDACTED]. In addition, the facility did not have an advance directive care plan for resident #1 which addressed the resident's code status. Documentation in resident #1's medical record indicated the facility staff had multiple meetings with the resident to discuss the resident's code status and declining medical condition. On [DATE], SW (Social Worker)-D met with a hospice RN (Registered Nurse), resident #1, and the resident's spouse. Documentation regarding the meeting with resident #1 indicated the resident "...only wanted CPR one time." After the hospice nurse provided education to resident #1 regarding the risks of rib fractures and the low success rate of CPR, documentation indicated the resident again stated "...wanted CPR done, but just one time then quit." Resident #1's medical record did not include documentation that further meetings/discussions with the resident had been completed to determine what the resident's interpretation of having CPR done "one time" meant. On [DATE], the hospice RN documented resident #1's medical condition was deteriorating and the resident was experiencing an increase in difficulty with breathing, swallowing, talking and getting words out. The hospice RN faxed this information to the physician and questioned the need for the physician to re-address the resident's full code status. The physician's assistant indicated resident #1 would be seen Thursday night, [DATE]. A care conference summary note dated [DATE] documented that a meeting was held with resident #1 and several family members. The resident's declining status was discussed during this meeting and included "very little intake" by the resident and end of life issues. Resident #1's code status remained unchanged after this meeting, however it was noted the facility was going to attempt to involve the medical director to over-ride the resident's full code choice based on medical futility (has little positive outcome). On [DATE], the hospice RN documented resident #1 had minimal oral intake, had declining medical status, and was moving towards actively dying. This information was faxed to the resident's physician, as well as a request to change the resident's code status to a DNR, based on medical futility. The physician's assistant responded by stating the facility should check with "medical legal" about changing the resident's code status. Nurse's notes and the facility investigation documented on [DATE] at 12:05 a.m., RN-H and CNA (Certified Nursing Assistant)-E witnessed resident #1 take his last breath and assessed the resident's pulse to be "thready." RN-H called for staff to help, applied the AED (Automated External Defibrillator), placed a board under the resident, and began chest compressions as directed by the AED. During this time, RN-G verified the resident's medical record indicated the resident's code status to be a full code. However, the nurses expressed confusion regarding the resident's wishes, because staff had heard that resident #1 only wanted "one round" of CPR and possibly no compressions. The medical record did not provide any direction for staff to follow regarding the resident's wishes of CPR, so RN-G called hospice staff for clarification. The hospice staff indicated the only thing documented about resident #1 was that the resident was a full code, and the nurse could call the resident's family for clarification. RN-G then called the resident's spouse, who initially indicated staff were to continue CPR, but later directed the staff to stop CPR. Minutes later the resident's daughter/ POAHC (Power of Attorney for Health Care) called the facility and directed staff to resume CPR and call 911 because the resident was a full code. The facility's lack of planning and understanding of the resident's resuscitation wishes led to staff confusion and delays in potentially life-saving treatment. In addition, the facility failed to contact the resident's POAHC for clarification and took direction from another family member instead. According to the Gold Cross Ambulance report dated [DATE], the facility called 911 at 12:26 a.m. (21 minutes after the resident was breathless and pulseless). The paramedics arrived at the facility at 12:28 a.m. The report notes, "Given the patient's down time of greater than 20 minutes, initial rhythm of asystole, and general presentation" an emergency room physician was contacted and gave permission to stop resuscitation. The resident was shortly after pronounced dead in the facility. On [DATE] at 9:00 a.m., surveyor # interviewed DON (Director Of Nursing)-B, NHA-A, and ADON (Assistant Director Of Nursing)-C regarding resident #1. DON-B, NHA-A and ADON-C indicated they did not know what "one round" of CPR meant to resident #1 and they admitted not exploring what "one round" of CPR meant to resident #1. ADON-C indicated the resident's daughter was included in the care conference meeting via the telephone on [DATE], and asked to be taken off the speaker phone at one point. Resident #1's daughter told staff they should not discuss end of life issues in front of resident #1's spouse because the spouse doesn't understand and gets very upset. ADON-C indicated resident #1's daughter told staff the resident's code status could be reviewed after the daughter's arrival to the facility on [DATE]. On [DATE] at 2:00 p.m. surveyor # interviewed NHA-A and DON-B regarding resident #1. NHA-A and DON-B indicated staff were use to calling hospice staff first for any issues, but should have called 911 first. NHA-A and DON-B stated they believed staff would have called 911 sooner, if they were not trying to seek clarification for the resident's CPR wishes. On [DATE] at 2:05 p.m., surveyor # interviewed SW-D regarding resident #1. SW-D indicated she did not follow up with resident #1 to explore what "one round" of CPR meant to the resident after the resident informed SW-D of this wish on [DATE]. SW-D indicated staff were verbally informed that resident #1 wanted "one round" of CPR and no fractured ribs. However, resident #1's advance directives and care plan did not reflect the resident's request for "one round" of CPR. SW-D indicated she shared this information verbally with staff, and "just left it alone" because it was her belief that once CPR was initiated, it could not be stopped. SW-D indicated she did not clarify or review resident #1's wishes with the resident or the staff to have just "one round" of CPR. On [DATE] at 9:20 a.m., surveyor # interviewed RN-G via the telephone. RN-G verified the above scenario and indicated CPR was stopped for ,[DATE] minutes before the resident's POAHC called the facility and directed them to continue. RN-G also stated after contacting the resident's spouse, an attempt was made to contact the daughter, who was the POAHC, but the daughter's phone number must have been incorrect in the medical record. According to the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, "Interruptions of chest compressions ... can compromise vital organ perfusion. Accordingly lay rescuers should not interrupt chest compressions ... In addition lay rescuers should continue CPR until an AED arrives, the victim wakes up, or EMS personnel take over CPR (Class IIa, LOE B). Healthcare providers should interrupt chest compressions as infrequently as possible and try to limit interruptions to no longer than 10 seconds, except for specific interventions such as insertion of an advanced airway or use of a defibrillator." Although the facility had multiple discussions with the resident regarding their code status, the resident insisted his choice was to remain a full code. When the facility knew the resident was declining, was receiving hospice care, wanted "one round" of CPR, and CPR status was a full code, the facility did not develop a plan or seek clarification of the resident's wishes to address what would or should be done if the resident presented to be breathless and pulseless. The facility's failure to have system so that resident's wishes concerning advance directives accurately reflected his wishes and could be readily identified by staff in an emergency created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], by which time the facility educated all nursing staff prior to working their next shift regarding their CPR policy and procedure, to include residents that receive hospice services and request CPR. The education on [DATE] directed staff to call 911 if the resident is a full code and on hospice or not.

Based on interview and record review, the facility did not ensure 1 (resident #1) of 9 sampled residents received the necessary care and services to attain or maintain the highest practicable well-being when life-sustaining procedures were not implemented in a timely manner. Resident #1 was receiving hospice care and verbalized to staff the desire to receive CPR (CardioPulmonary Resuscitation) if needed. When the resident was found to have stopped breathing and was pulseless, staff immediately applied an AED (Automated External Defibrillator) and followed its direction to begin compressions, however staff waited 21 minutes before calling 911. Additionally, staff sought clarification from a family member who was not the resident's POAHC (Power Of Attorney for Health Care), which led to a ,[DATE] minute period when CPR was stopped and then restarted. Life-saving interventions were significantly delayed, which had the potential to contribute to resident #1's demise. The failure to immediately call 911 and the failure to continue CPR according to professional standards of practice created a finding of immediate jeopardy. The jeopardy began on [DATE]. The NHA (Nursing Home Administer) was informed of the immediate jeopardy on [DATE]. The facility had removed the jeopardy and corrected this deficient practice on [DATE], thus this is being cited as past noncompliance. Findings include: According to the facility's CPR policy dated [DATE], the purpose of the policy was to provide guidelines to staff for initiating of CPR. The policy indicated residents who chose to be full code status would wear a blue bracelet and have a blue dot on their chart for quick reference. The policy indicated the chances of survival are greater if CPR is initiated immediately. The policy notes "The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver advanced life support. When staff assess a resident to be pulseless, breathless, and unresponsive the policy directs staff to first inititiate a "code" and to designate a staff person to call 911. The facility's contract with the hospice agency, Affinity Visiting Nurses, indicated the facility was to contact hospice immediately if the resident had a change in condition. The hospice after hours contact information form directed staff to "Do NOT call 911" in bold letters. Resident #1's undated face sheet indicated the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's admission MDS (Minimum Data Set) assessment documented resident #1's cognition was intact and the resident was his own decision maker. On [DATE], staff informed resident #1's physician that the resident was choosing to have CPR, if needed. The physician's monthly orders for ,[DATE] and ,[DATE] both documented the resident's code status was a full code. Resident #1's "Power Of Attorney for Health Care" (POAHC) document completed on [DATE] assigned the resident's daughter to be the POAHC if the resident was no longer able to make health care decisions. Resident #1's Hospice admission progress note documented the resident began receiving hospice care services on [DATE]. Despite the resident's choice to be a full code, resident #1's code status was to be DNR (Do Not Resuscitate). Under Wisconsin law, there must be a signed physician's orders [REDACTED]." Hospice documentation did not reflect resident #1's choice to be a "full code." Resident #1's medical record did not include documentation that the facility had obtained a physician's orders [REDACTED]. Resident #1's hospice care plan dated [DATE] indicated the resident was a DNR status and directed staff to "Do not call 911- call hospice first." On [DATE], resident #1's hospice care plan was updated to indicate the resident was a full code in the "Directives" section. However, the "interventions" portion of the hospice care plan indicated the resident's code status was DNR and directed staff to "Do not call 911- call hospice first." Even though the hospice documentation did not reflect resident #1's choices, the facility's medical record continued to indicate the resident was a full code and the facility never received a DNR order from the resident's physician. The facility did not have an advance directive care plan that addressed the resident's code status. In addition, the facility did not take steps to provide clear direction to staff for when to call 911 and if the hospice policy or the facility's CPR policy should be followed. On [DATE] at 9:00 a.m. DON (Director Of Nursing)-B, NHA-A, and ADON (Assistant Director Of Nursing)-C verified to surveyor # the facility talked with resident #1 multiple times regarding his situation of being on hospice and being a full code and the resident chose to remain a full code. DON-B, NHA-A, and ADON-C verified the resident's condition was deteriorating throughout his stay. On [DATE] at 9:31 a.m., NHA (Nursing Home Administrator)-A verified to surveyor # , resident #1 remained a full code throughout his stay in the facility. The medical record indicated the resident's code status did not change throughout the rest of the resident's stay in the facility and the resident remained a full code the whole time. Nurse's notes and the facility investigation documented on [DATE] at 12:05 a.m., RN-H and CNA (Certified Nursing Assistant)-E witnessed resident #1 take his last breath and assessed the resident's pulse to be "thready." RN-H called for staff to help, applied the AED (Automated External Defibrillator), placed a board under the resident, and began chest compressions as directed by the AED. During this time, RN-G verified the resident's medical record indicated the resident's code status to be a full code. However, the nurses expressed confusion regarding the resident's wishes, because staff had heard that resident #1 only wanted "one round" of CPR and possibly no compressions. The medical record did not provide any direction for staff to follow regarding the resident's wishes of CPR, so RN-G called hospice staff for clarification. The hospice staff indicated the only thing documented about resident #1 was that the resident was a full code, and the nurse could call the resident's family for clarification. RN-G then called the resident's spouse, who initially indicated staff were to continue CPR, but later directed the staff to stop CPR. Moments later the resident's daughter/ POAHC (Power of Attorney for Health Care) called the facility and directed staff to resume CPR and call 911 because the resident was a full code. The facility's lack of planning and understanding of the resident's resuscitation wishes led to staff confusion and delays in potentially life-saving treatment. In addition, the facility failed to contact the resident's POAHC for clarification and took direction from another family member instead. According to the Gold Cross Ambulance report dated [DATE], the facility called 911 at 12:26 a.m. (21 minutes after the resident was breathless and pulseless). The paramedics arrived at the facility at 12:28 a.m. The report notes, "Given the patient's down time of greater than 20 minutes, initial rhythm of asystole, and general presentation" an emergency room physician was contacted and gave permission to stop resuscitation. The resident was shortly after pronounced dead in the facility. On [DATE] at 9:00 a.m. DON-B and NHA-A verified to surveyor # that staff should have called 911 immediately after calling the code. NHA-A and DON-B indicated staff were provided education on [DATE] directing staff to call 911 if the resident is a full code and on hospice or not. On [DATE] at 10:30 a.m., CNA-E verified to surveyor # she was present when the resident took his last breath. CNA-E verified staff immediately called a code, placed a board under the resident, attached the AED, and RN-H followed the direction to begin compressions. CNA-E indicated the RN had done two sets of 30 compressions before the CNA left the room. On [DATE] at 12:15 p.m., CNA-F verified to surveyor # she had joined the two RNs who were doing CPR after it had been going on for a while to relieve them. CNA-F did not recall the time, but verified compression only CPR was being provided. CNA-F indicated shortly after she had taken over, the paramedics arrived and took over. CNA-F stated the paramedics placed their monitor on the resident and did not do CPR but called the ER physician to get the order to stop CPR. On [DATE] at 2:00 p.m. NHA-A and DON-B verified to surveyor # staff were used to always calling hospice first for any issues. NHA-A and DON-B also verified RN-H had heard the resident only wanted one round of CPR and no compressions, and they believed staff would have called 911 sooner if they were not trying to seek clarification for the resident's CPR wishes. On [DATE] at 9:20 a.m. surveyor # interviewed RN-G via telephone. RN-G verified the above scenario from [DATE] and indicated CPR was stopped for ,[DATE] minutes before the resident's POAHC called the facility and directed them to continue. RN-G also stated after contacting the resident's wife, an attempt was made to contact the daughter, who was the POAHC, but the daughter's phone number must have been documented incorrectly in the medical record. According to the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, "Interruptions of chest compressions ... can compromise vital organ perfusion. Accordingly lay rescuers should not interrupt chest compressions ... In addition lay rescuers should continue CPR until an AED arrives, the victim wakes up, or EMS personnel take over CPR (Class IIa, LOE B). Healthcare providers should interrupt chest compressions as infrequently as possible and try to limit interruptions to no longer than 10 seconds, except for specific interventions such as insertion of an advanced airway or use of a defibrillator." The facility's failure to have a system so that this resident's wishes concerning advance directives accurately reflected his wishes and could be readily identified by staff in an emergency, and the failure to implement measures to restore pulse and breath if possible (immediately call 911 and to continue CPR without stopping) created a finding of immediate jeopardy. The facility removed the jeopardy on [DATE], by which time the facility educated all nursing staff prior to working their next shift regarding their CPR policy and procedure, to include residents that receive hospice services and request CPR. The education on [DATE] directed staff to call 911 if the resident is a full code and on hospice or not.

Based on observation, interviews and record review, the facility did not ensure the environment remained as free of accident hazards as possible and did not provide adequate supervision and assistive devices to prevent accidents for 1 (resident #7) of 8 sampled residents reviewed for accidents and supervision. Resident #7 had spilled hot coffee during a meal resulting in a second degree (partial thickness) burn to the right thigh. When the facility became aware of the burn and the resident's risk for spilling liquids, appropriate and timely assessments and interventions were not taken to address the resident's safety, supervision, assistive device and treatment needs. Subsequently, 8 days later, the resident again spilled hot coffee to the right thigh resulting in a third degree (full thickness) burn. The facility again did not implement appropriate and timely assessments and interventions to address the resident's safety, supervision, assistive device and treatment needs. The lack of appropriate devices and supervision to ensure resident #7's safety while consuming hot fluids resulted in a finding of Immediate Jeopardy, which began on 4/5/12. The facility was notified of the finding on 4/23/12. The Immediate Jeopardy was removed on 4/21/12. Findings include: According to an article from medscape.com entitled 'Older Adults and Burns' dated 9/30/2008, the significant morbidity of burns among older adults should make preventing these injuries from occurring the most important goal for healthcare workers. Epidemiological studies have indicated the majority of burn injuries among older adults are preventable and primary prevention strategies at the policy level are necessary to minimize thermal injuries to the older adult population. Older adults lacking adequate supervision or displaying at-risk behaviors should be evaluated. According to the face sheet dated 4/2/12, resident #7 is [AGE] years old and was originally admitted to the facility on [DATE]. According to the "[DIAGNOSES REDACTED]. According to the most recent change in condition MDS (Minimum Data Set) dated 2/28/12, resident #7 had severe cognitive impairment, no behaviors, no pain, required extensive assist with ADLs (Activities of Daily Living) and was independent with set up assist only for eating. On 4/18/12 surveyor # reviewed the plan of care for resident #7. According to the "Self Care Deficit" plan of care last revised 3/6/12, resident #7 was at risk for falls secondary to multiple factors including tremors, episodes of confusion, forgetfulness, distractibility, difficulty finding words and not always understanding the content of a conversation. According to the "Care Guidelines" last updated 4/12/12 resident #7 was usually cooperative, but confused. The "Care Guidelines" directed staff to assist with set up for meals and to push fluids for resident #7. According to an incident report dated 4/19/12 written by LPN (Licensed Practical Nurse)-N, on 4/5/12 at 12:00 p.m. LPN-N noted a reddened area to resident #7's right upper thigh during an unrelated skin check. The report indicated the LPN at first thought the reddened area was a rash, but was then notified the resident was found to have coffee spilled on her pants and must have spilled it in the dining room and not told anyone. The incident report also noted the resident had been observed earlier in the dining room to have covers on her coffee. On 4/20/12 at 1:48 p.m. LPN-N verified to surveyor # via telephone, on 4/5/12 when the resident was found to have a burn from coffee LPN-N had the CNAs (Certified Nursing Assistants) change the resident's clothes as the only intervention provided for the resident. LPN-N also verified to surveyor # no changes were made to the resident's plan of care, no physician update was done, no incident report was completed, no thorough assessment of the burn was completed, no root cause analysis was completed, no other departments such as dietary or therapy were notified, but the incident was passed along in report to the next shift. On 4/6/12 the facility notified resident #7's physician via fax which read, "Resident has blisters on right thigh due to spilled coffee." The facility did not receive a response from the physician until 7:15 p.m. when the facility called an on call physician and received a verbal order for Silvadine cream with a nonstick dressing twice daily until healed and to have the physicians assistant check on it next week. According to the nurses notes on 4/7/12 at 1:51 p.m. resident #7's skin status was noted to have areas of concern and the pharmacy should be sending the cream for the resident's right thigh burn. The treatment administration record shows the treatment for [REDACTED]. The nurses notes on 4/8/12 at 2:06 p.m. indicate one of two blisters to resident #7's thigh had broken open and there were no signs of infection. The nurses notes on 4/8/12 at 8:54 p.m. noted resident #7 had no blisters present, the dressing was soaked with serous fluid and the resident had no complaints. On 4/9/12 at 2:08 p.m. it was noted in the nurses notes the resident expressed a little pain with the dressing change to the thigh. On 4/9/12 at 7:49 p.m. it was noted resident #7 had a blistered area to the right upper thigh and had no pain. On 4/10/12 at 9:48 p.m. it was noted the resident had no complaints of pain. According to a "Provider Round Sheet" on 4/12/12 resident #7 was seen by a Physician Assistant who noted "Right thigh burn - nearly resolved". On 4/20/12 at 1:20 p.m. surveyor # interviewed RNS (Registered Nurse Supervisor)-W via telephone. RNS-W verified she had no knowledge of resident #7's burn until several days after the incident when therapy "mentioned" it. RNS-W did not recall the date she was notified, but did verify she changed the care plan for resident #7 at this time with an undated posting that directed staff to do the following interventions during meal and snack times: 1. Coffee or liquids must be covered to prevent spills (which was implemented prior to the first spill). 2. Use clothing protector. 3. Apply chux (absorbent disposable pad) over the lap to protect from spills. Although RNS-W updated the resident's care plan, RNS-W verified to surveyor # she was aware of staff reports that the resident would remove the cover from the coffee cup. According to the Treatment Administration Record, the above interventions started being implemented during the a.m. shift of 4/13/12. On 4/13/12 at 1:49 p.m. the nurses notes indicated resident #7 spilled water on her lap at lunch and the new protocol of covered cups, chux on lap and the clothing protector are in place. No changes to resident #7's plan of care were made. On 4/13/12 at 2:52 p.m. an incident report was completed that indicated the resident had spilled hot coffee on her right thigh again. The report noted the resident had had a cloth over her lap but had removed it prior to the spill. A cold compress was applied, blisters, redness and bleeding were noted and staff continued the treatment of [REDACTED]. The safety interventions listed were to remind the resident not to remove the cloth from her lap while drinking coffee. The incident report then noted the resident's cognition to be "confused" and that the resident's physician was contacted and the family of the resident was notified. When the facility was aware the resident spilled hot coffee a second time and received another burn to the same area on her right thigh no changes to the resident's plan of care were made, no thorough assessments of the resident's burn or environment were completed to ensure the resident's safety and appropriate treatment. Although the facility faxed resident #7's physician on 4/13/12 and indicated the second burn had redness and blisters present (indicating a second degree burn), no physician response was received until 4/17/12. According to the Treatment Administration Record, the facility used the treatment order for the first burn of Silvadine cream twice daily to treat the second burn before receiving an order for [REDACTED]. The facility did not complete a thorough assessment of resident #7's burn until 4/18/12 when WCN (Wound Care Nurse)-X assessed it with surveyor # present. Surveyor # observed the burn on the right anterior thigh to be a full thickness (third degree burn) with the center of the base to be hard and yellow surrounded by reddened wound tissue. WCN-X documented the burn to be 2 X 4 cm (Centimeters) with yellow tissue, scant serous drainage and reddened surrounding tissue. Although WCN-X did not document the thickness or degree of resident #7's burn, on 4/20/12 at 1:37 p.m. WCN-X verified to surveyor # the hard yellow base of the burn indicated a full thickness or third degree burn. WCN-X also verified to surveyor # a burn that evolved from a second or partial thickness burn to a third or full thickness burn may need a different treatment, the physician should be notified and a wound or burn clinic evaluation should be considered. WCN-X also verified to surveyor # she did not make any recommendations for resident #7's burn because she was under the impression the physician was already aware that the burn had deteriorated to a third degree or full thickness burn. The physician was not notified when the wound was assessed to have evolved from a second to a third degree burn. On 4/18/12 at 5:44 p.m. surveyor # recorded the coffee temperatures during the evening meal as follows: 150 degrees Fahrenheit at 5:44 p.m. (3rd degree burn could occur in 1-2 seconds) 148 degrees Fahrenheit at 5:46 p.m. (3rd degree burn could occur in 2 seconds) 140 degrees Fahrenheit at 5:48 p.m. (3rd degree burn could occur in 5 seconds) 136 degrees Fahrenheit at 5:50 p.m. (3rd degree burn could occur in 5-15 seconds) The facility made no changes to resident #7's plan of care until 4/19/12 when the facility changed the resident's coffee to half coffee and half milk in an effort to cool the coffee. On 4/19/12 at 10:02 a.m. CNA (Certified Nursing Assistant)-AA verified to surveyor # staff were currently directed to keep a chux pad on the resident's lap and a cover on hot liquids while the resident is drinking, but the resident continues to remove the beverage lids and removes the chux from her lap. On 4/19/12 at 1:20 p.m. DM (Dietary Manager)-Y verified to surveyor # he was not aware of any resident's being burned from the coffee and if he had been notified the coffee temperatures could have been evaluated and adjusted accordingly. On 4/19/12 at 1:30 p.m. ST (Speech Therapist)-S verified to surveyor # she had been working with resident #7 since 4/13/12 to rule out aspiration and for chewing and swallowing difficulties. ST-S verified prior to 4/18/12 she was unaware of resident #7's burns from spilled coffee and that had she been notified after the first spill there were many assistive devices available that could have been provided to the resident in an effort to avoid spilling and decrease the likelihood of the resident removing the covers. On 4/19/12 at 1:15 p.m. DON (Director Of Nursing)-P verified to surveyor # there was no assessment information or incident report documented from resident #7's first burn injury on 4/5/12, but the nurse would be coming in today to chart on it as a late entry. DON-P also verified to surveyor # she was not aware of the coffee burn from 4/5/12 until several days or a week later and that staff were not inservices after either burn incident, there were no thorough investigations or root cause analysis completed and that dietary or speech therapy were not updated immediately on these incidents. DON-P also verified to surveyor # resident #7 suffered a second degree burn from the spilled coffee on 4/5/12 and a third degree burn from the coffee spilled on 4/13/12. DON-P did not know the date the care plan had been updated and was not aware of the resident's noncompliance with the interventions. On 4/20/12 the facility received an new order initiated by ST-S, which implemented a "Kennedy cup" with a straw to decrease spillage due to tremors for resident #7. On 4/20/12 the facility also notified resident #7's physician via fax that the resident's burn measured 2 X 4 cm and now had yellow slough to the base. Resident #7's physician (physician-Z) came to the facility to assess the resident on 4/20/12. According to the physicians progress note from this visit resident #7's tremor was getting more pronounced, the burn was continuing to heal and the resident had no apparent pain. The progress note also indicated the burn measured approximately 4 X 4 cm with an area of approximately 2 X 4 cm of adherent eschar which "...may eventually need debridement". The physician also noted the burn as a second degree burn. On 4/23/12 at 1:40 p.m. physician-Z verified to surveyor # the area of the burn adhered with eschar was probably a third degree or full thickness burn as he saw it on 4/20/12. Physician-Z also verified to surveyor # the facility probably should have updated him on 4/5/12 when they knew the reddened area to resident #7's thigh was a burn, but that it didn't blister until 4/6/12 and he was notified then. Physician-Z also verified he didn't see the fax that was sent on 4/13/12 when the second burn occurred until 4/17/12 and that the facility probably should have updated him when the burn deteriorated to a full thickness burn, but that he would not have changed the treatment had he been updated.

Based on staff and resident interviews and record review, the facility did not ensure 2 (residents #1 and #3) of 12 sampled residents received adequate supervision. When resident #1 experienced a change in his normal behavior and demonstrated behavioral changes, which included sexual gestures, entering peers' rooms, staring at female peers and touching female peers; the facility did not fully assess resident #1's behavioral changes and develop an adequate supervision plan. Resident #3, who was identified at high risk for falls and had sustained a recent pelvic fracture, was not provided supervision as directed in her care plan. Findings include: 1. On 5/4/11 surveyor # completed a record review for resident #1. The face sheet, dated 4/11/11 and contained within the medical record, indicated resident #1 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The facility completed a quarterly MDS (Minimum Data Set), dated 2/8/11. The MDS documented resident #1 was able to understand others and make himself understood. The MDS further documented resident #1 had a recent history of hallucinations. The resident progress notes dated 3/4/11 at 8:07 p.m. indicated resident #1 was on fifteen minute checks and was alert and oriented times three. The progress notes for resident #1 on 3/21/11 at 1:44 p.m. documented resident #1 was "...confused at this am shift. Resident grabbing at air and staff...". The progress note on 3/21/11 at 1:55 p.m. documented, "Resident wandered into another residents room and was accused by that resident of telling her to put her legs down off her recliner chair and take her pants off. Resident later stated to social services that he did not remember the incident...". The "Care Guidelines", dated 2/15/11, documented resident #1 was on fifteen minute checks and directed staff to be aware the resident could be impulsive. On 3/21/11 the facility added, "...Remind res. (resident) to not go into other female res. rooms...". The progress notes on 3/23/11 at 10:24 a.m. documented, "Late Entry: Resident has made comments toward staff, about 'Lets go to another room' will run his hands up and down staff sides, and has made sexual comments. Is reminded that this is not appropriate and he will stop." On 3/24/11 the facility implemented behavior monitoring for resident #1 to include monitoring for making sexual comments to staff. Resident #1 was moved to another unit within the facility on 3/25/11. No further changes to resident #1's supervision plan were implemented. A facility investigation summary dated 4/1/11 documented on 4/1/11 on the night shift, resident #1 walked up behind a female peer and either tried to "bend her over or hump her." The investigation further documented the facility identified, through resident and staff interviews, that on at least one other night resident #1 had been in other residents' rooms, and apparently touched a resident's (resident #2) toes and lower leg, and had instances of peering or staring at female peers while standing in their rooms. On 4/1/11 the facility implemented a temporary care plan, which documented, "Temporary Problem/Need: Touching other residents; going into other resident's room and touching them or watching them. Goal: safety of others...Approach/Intervention: Continue 15 min. checks, Sensor alarm over doorway to indicate that he has left room. If alarming have him come down to desk or lounge to avoid going into other resident's rooms during night. Monitor closely when around other residents. Offer a snack when unable to sleep. Has taken pain medication and Lorazepam when unable to sleep. If resident touches another resident inappropriately call 911." Resident #1 was evaluated by the nurse practitioner on 4/7/11. The progress note documented resident #1 had behaviors, which fluctuated, and had made sexual comments to staff. The progress note indicated on 4/1/11 resident #1 was standing behind another clothed resident in the hall with his arms around her trying to bend her over. The note further indicated resident #1 had been known to stare at other female residents. The nurse practitioner made changes to resident #1's medication regimen and recommended neuropsych evaluation for diagnostic clarification. As of 4/29/11 (the day of resident #1's discharge) that testing had not been completed. The behavior monitoring record, dated 4/11/11 at 10:19 a.m. documented resident #1 had one episode of "makes sexual comments to staff". No further details were noted. On 4/14/11 the facility updated the comprehensive plan of care to include the following: Problem: inappropriate interactions...Evidenced by: touching other residents; going into other resident's room and touching them or watching them...Approach: continue 15 minute checks. Sensory alarm on door way frame at night to indicate that he had left the room. If alarming have him come down to desk or lounge to avoid going into other resident's rooms during the night. Monitor closely when around other residents. Offer a snack when unable to sleep. Offer pain medication for discomfort. Again on 4/14/11 the plan of care was further modified to include: "...Needs to be in visual range when up at nite to avoid going into other resident's rooms during the night...Motion sensor on bathroom door (of adjoining bathroom)...". There were no changes made to resident #1's supervision plan during the day time and evening hours, only at night. The social services notes from 3/2/11 to 4/24/11 did not contain any documentation regarding resident #1's recent sexual behaviors or behavioral assessment. The medical record, including the progress notes, from 3/2/11 to 4/24/11 did not contain any behavioral assessment. Social service progress notes dated 4/25/11 documented, "Incident with (resident #1) involving a female resident across the hallway from (resident #1). Female resident reported that (resident #1) touched her inappropriately, i.e. attempted to spread her legs a part while sitting in her chair. (Resident #1) denied the incident. The police were contacted and investigated and (resident #1) will be charged...will be moved (to another unit)...the move was for the welfare of the female resident involved in the incident...". Progress notes regarding resident #1 on 4/25/11 at 12:28 p.m. indicated, "Staff reported resident loitering around other resident's room, plan to change to turn motion alarm on both hallway and bathroom at all times when resident is in room." The progress note at 1:25 p.m. indicated at 12:00 p.m. resident #1 allegedly attempted to spread a female resident's knees apart, and indicated the female resident (resident #2) was "pressing charges". The plan was to implement the use of motion sensors on both exit doors of resident #1's room, and staff needed to accompany resident #1 at all times when the resident was out of his room. On 5/4/11 at 8:33 a.m. surveyor # interviewed CNA (Certified Nursing Assistant)-B regarding the incident involving residents #1 and #2 on 4/25/11. CNA-B stated on 4/25/11 at approximately 11:50 a.m. she responded to resident #2's call light. CNA-B stated resident #2 was "really upset" and reported that "that man", describing resident #1, had been in her room and attempted to spread her legs apart. CNA-B stated resident #2 had a very worried look on her face and was upset. CNA-B immediately reported the incident to LPN (Licensed Practical Nurse)-E. CNA-B stated she worked with resident #2 the day following the incident, and resident #2 remained upset and worried. CNA-B stated resident #2 had informed her that every time she heard a noise, she was afraid it was resident #1 and became anxious. On 5/4/11 at 8:42 a.m. surveyor # interviewed LPN-E regarding the incident involving residents #1 and #2 on 4/25/11. LPN-E verified CNA-B informed her of the allegation of resident #1 inappropriately touching resident #2 on 4/25/11. LPN-E stated she immediately informed the DON (Director of Nursing)-A, who began the investigation. LPN-E verified, following the 4/25/11 event, resident #1 was placed on direct supervision whenever the resident was out of his room. LPN-E verified that, prior to the incident on 4/25/11, resident #1 had been on fifteen minute checks, but no further supervision was planned during the day or evening hours. LPN-E stated she was aware a motion sensor was utilized at night, and resident #1 required direct supervision if he was out of his room at night; but LPN-E was not aware of any such plan during the day or evening shifts. LPN-E stated resident #1 was independently ambulatory with a walker and was able to move about the facility independently without restriction. During the 5/4/11 at 8:33 a.m. interview with surveyor # CNA-B stated prior to the 4/25/11 event, resident #1 had been on 15 minute checks, but had no further supervision plan during the day or evening hours. CNA-B stated she was aware a motion sensor was utilized at night, and resident #1 required direct supervision if he was out of his room at night. CNA-B indicated she was not aware of any such plan during the day or evening shifts. CNA-B stated resident #1 was independently ambulatory with a walker, and was able to move about the facility independently without restriction. During an interview with surveyor # on 5/4/11 at 8:30 a.m. CNA-D stated resident #1 had been on fifteen minute checks prior to the incident on 4/25/11 with resident #2. CNA-D stated no other supervision plan was in place during the day or evening shifts, and resident #1 was able to ambulate independently throughout the facility during the fifteen minute time periods. CNA-D stated she was aware resident #1 had a history of [REDACTED]. During an interview with surveyor # on 5/4/11 at 9:55 a.m. RN (Registered Nurse)-C verified resident #1 had been on 15 minute checks, but had no further supervision plan during the day or evening hours prior to 4/25/11. RN-C stated she was aware a motion sensor was utilized at night, and resident #1 required direct supervision if he was out of his room at night. RN-C stated resident #1 was independently ambulatory with a walker, and was able to move about the facility independently without restriction. RN-C verified following the 4/25/11 event, resident #1 was moved to a different unit and was placed on direct supervision whenever he was out of his room. RN-C verified motion sensors were utilized to the exits of the room to alert staff when resident #1 exited his room. On 5/4/11 at 10:05 a.m. surveyor # interviewed SW (Social Worker)-F. SW-F was not aware of any direct supervision plan in place, outside of the 15 minute checks, for resident #1 during the day and evening hours. SW-F stated she spoke with resident #1 following the allegation, and he denied having had contact with resident #2. During an interview with surveyor # on 5/4/11 at 10:20 a.m. CNA-G verified resident #1 had been on 15 minute checks, but no further supervision plan during the day or evening hours. CNA-G stated she was aware a motion sensor was utilized at night, and resident #1 required direct supervision if he was out of his room at night. CNA-G was not aware of any such plan during the day or evening shifts. CNA-G stated resident #1 was independently ambulatory with a walker and was able to move about the facility independently without restriction. During an interview with surveyor # on 5/4/11 at 8:02 a.m., DON (Director of Nursing)-A verified no direct supervision plan was in place for resident #1 during the day or evening hours prior to the 4/25/11 incident. DON-A stated motion sensors were utilized at the door entrances to resident #1's room only during the night shift, and direct supervision was implemented only during the night shift if resident #1 exited his room. DON-A stated following the 4/25/11 incident, a direct supervision plan was implemented for resident #1 at all times when he was out of his room. DON-A stated the facility did not feel a direct supervision plan had been necessary during the day and evening shifts due to the number of staff around; therefore, no supervision plan outside of the 15 minute checks had been implemented during the day or evening shifts prior to the 4/25/11 incident. The progress notes on 4/29/11 documented resident #1 was discharged from the facility per his wishes. The social service note on 4/25/11 documented, "(Resident #2) reported a male resident touching her inappropriately in trying to spread her legs a part. The police were notified and the male resident will be charged...(resident #2) had initially told writer that she was scared right after the incident occurred...". The social service note on 4/27/11 documented, "On 4/26/11 writer met with (resident #2) to see how she was doing emotionally following the incident that occurred on 4/25/11. (Resident #2) indicated that she wasn't feeling that good and that the male resident involved in the incident scared her. She said she didn't sleep good because she was thinking about what happened...". The physician progress notes [REDACTED]. No recent changes. She did have a significant stressful experience yesterday when another male resident came in and asked her to spread her legs...This was stressful to her, and she was very anxious afterward but seems to be doing better today...We discussed with her in detail the stressful experience from yesterday. She does not seem to have any serious affects from this. She should be using alprazolam (an anti-anxiety medication) if she has increased anxiety...". On 5/4/11 surveyor # reviewed the medical record for resident #2. The face sheet, dated 5/3/11, indicated resident #2 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], documented resident #2 was able to make herself understood, understand others and was cognitively intact. Resident #2 remained her own legal decision maker. The progress notes dated 4/25/11 documented resident #2 reported a male resident who lived across the hall, came into her room, placed his hands on her knees and tried to move her legs apart. The note documented resident #2 was "visibly upset" when the CNA responded to the call light. During the interview with surveyor # on 5/4/11 at 9:55 a.m. RN-C verified resident #2 was alert and oriented and able to recall events appropriately. RN-C stated resident #2 remained anxious the day following the event of 4/25/11. On 5/4/11 at 8:20 a.m. surveyor # interviewed resident #2. Resident #2 was alert and oriented and recalled the recent events involving resident #1. Resident #2 stated during the night shift a few weeks ago, a male resident, who she believed to be resident #1, came into her room while she was sleeping and "twinkled" her toes, then began touching her ankle and leg. Resident #2 described "twinkled" to mean touching/grabbed lightly. Resident #2 stated she told him to stop or she would scream, and resident #1 left the room. Resident #2 stated resident #1 did not say anything to her, but she was frightened because she did not know what he was going to do. Resident #2 stated again on 4/25/11 resident #1 entered her room around 12:00 p.m. while she was seated in her chair eating lunch. Resident #2 stated resident #1 came to her doorway twice and asked her about her meal. Then the third time, resident #1 entered into the room and approached resident #2. Resident #2 stated resident #1 stood in front of her and stated, "Alright let's go." Resident #2 stated resident #1 then reached down and attempted to spread her knees apart. Resident #2 stated she squeezed her knees together as hard as she could while resident #1 was trying to pull them apart. Resident #2 stated she told resident #1, "You better get out of here right now if you know what's good for you." Resident #2 stated resident #1 grumbled something she could not understand and exited the room. Resident #2 stated she immediately placed her call light on, and CNA-B responded. Resident #2 stated she informed CNA-B what had occurred; and shortly thereafter, the nurse came to the room as well as the police. Resident #2 stated she was very afraid at the time of the event and remained afraid after the event. Resident #2 stated she felt anxious every day and was nervous that resident #1 may come back. Resident #2 stated she was aware resident #1 no longer lived at the facility; therefore, she did feel a bit safer at the time of the interview. Resident #2 stated, "I have never been so scared in all my life. I didn't know what was going to happen. That's the second time I've been touched since I've been here. I am [AGE] years old, and I shouldn't have to be afraid." During the 5/4/11 at 10:05 a.m. interview with surveyor # , SW-F stated she conducted an interview with resident #2 immediately after the allegation was voiced. SW-F stated resident #2 was upset by the contact with resident #1; and per resident #2's statement, "She was so scared." SW-F stated although resident #2 was not able to name resident #1, she was able to describe where he lived and what he was wearing (which matched resident #1). SW-F verified resident #2 was upset following the incident, and the police were contacted. SW-F stated resident #2 wished to press charges against resident #1. SW-F stated she followed up with resident #2 the following day, and she remained upset. SW-F stated resident #2 expressed not sleeping well due to being anxious about the event. SW-F stated resident #2 was alert and oriented at the time, and verified resident #2 was able to make her own medical decisions (Power of Attorney for Health Care was not activated). SW-F was not aware of any direct supervision plan in place, outside of the 15 minute checks, for resident #1 during the day and evening hours. Surveyor # reviewed the police report. The report documented on 4/25/11 at 12:15 p.m. a police officer responded to the facility to investigate a possible sexual assault incident. The report indicated an arrest of resident #1 was completed on 4/25/11 at 2:30 p.m. for forth degree sexual assault. 2. The face sheet, dated 4/17/11 and contained within the medical record, indicated resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The history and physical from the hospital for resident #3, dated 3/17/11, indicated, "Severe dementia, fell at home on lawn, laceration with sutures right supraorbital ridge. Quite demented, disoriented to time and place, looking for her mother. Fractured pelvis." The facility completed a falls assessment for resident #3 on 3/17/11 using the Morse Fall Scale, giving her a score of 105. A score over 51 indicated a high fall risk. That form directed the facility to implement high risk falls preventions. Those included: a) remind resident to call for assist as needed, b) if resident is restless, unsteady, or impulsive do not leave them alone in the bathroom. On 3/18/11 at approximately 9:03 p.m. nurses' notes showed resident #3 was observed on the floor in her room calling out for help. The call light was clipped to her bed sheet. Resident #3 was uninjured. Resident #3 told staff that she was trying to go to the bathroom, when she slipped on her butt. Revisions to resident #3's care plan on 3/24/11 indicated the resident remained a high risk for falls on the Morse fall scale. Need for antianxiety meds. Follow Morse fall protocols. Severe cognitive impairment. Sometimes gets dizzy when up. History of fall with pelvic fracture and recent fall since admission. On 5/4/11 surveyor # reviewed a facility self-report regarding an allegation of CNA (Certified Nursing Assistant)-H threatening resident #3 on 4/24/11 at 11:30 a.m. The allegation was unsubstantiated. However, during an interview with surveyor # on 5/4/11 at 8:36 a.m. regarding the allegation, CNA-H indicated she had taken resident #3 to the bathroom on 4/24/11 around 11:30 a.m.; and resident #3 had to "sit awhile", because she was not done. CNA-H indicated she left the bathroom door open to give resident #3 her privacy and left the room twice to assist with other call lights across the hall and in the room next door. CNA-H indicated she checked on resident #3 but then left a second time, because the resident wasn't done on the toilet. CNA-H said she was gone about a minute in the room next door and heard the toilet flush in resident #3's bathroom. CNA-H indicated she ran into resident #3's bathroom and found the resident standing up and pulling her pants up. CNA-H indicated resident #3 had taken her gait belt off and had it draped over her walker, which was in front of her. CNA-H indicated she ran into the bathroom, because she did not want resident #3 to fall again and was concerned for the resident's safety. However, CNA-H indicated she thought resident #3 would be okay when she left the resident unattended, because she was only gone a short while and was right next door. On 5/4/11 at 9:00 a.m. surveyor # interviewed CNA-J regarding leaving residents unattended in the bathroom. CNA-J indicated she worked as a restorative aide and said that residents who were identified as high falls risk should not be left unattended when on the toilet. On 5/4/11 at 9:20 a.m. surveyor # interviewed CNA-K regarding leaving residents unattended in the bathroom. CNA-K indicated staff were not to leave a resident who was at risk of falls unattended on the toilet. CNA-K indicated staff needed to stay within arm's reach of that person, which could mean standing at the bathroom door to give the resident some privacy, but never farther away than that. CNA-K indicated residents identified at risk for falls were always to have their gait belt on. On 5/4/11 at 9:40 a.m. surveyor # interviewed LPN (Licensed Practical Nurse)-L regarding leaving residents unattended in the bathroom. LPN-L indicated residents at high risk of falls were always to be assisted with bathroom cares and never left alone when in the bathroom. On 5/4/11 at 10:10 a.m. surveyor # interviewed DON (Director of Nursing )-A regarding resident #3 and leaving residents unattended in the bathroom. DON-A confirmed resident #3 was at high risk for falls; and the facility protocol was to follow the Morse Falls guidelines, which included to supervise while on the toilet. DON-A indicated resident #3 often wanted privacy when on the toilet and verified CNA-H could have provided safety and privacy by standing at the door with it slightly open, providing supervision.

Based on staff and resident interview and record review, the facility did not ensure 1 (resident #1) of 11 sampled residents received adequate supervision. Resident #1 was admitted to the facility without a history of physical aggression. The resident began displaying signs of aggression on the second day of admit. Resident #1's aggression escalated. The facility placed resident #1 on 1:1 monitoring but only for short periods of time. Although the facility updated the physician, and medications were changed; the facility did not ensure resident #1 was supervised to ensure the safety of other residents. The facility did not complete a behavioral assessment in an attempt to determine possible causal factors for resident #1's aggressive, physical behaviors towards other residents. The facility did not develop a plan of care for resident #1's aggressive behaviors towards other residents until 1/18/11, which was after multiple aggressive contacts with other residents. Findings include: The face sheet, dated 1/10/11 and contained within the medical record, indicated resident #1 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The facility completed an MDS (Minimum Data Set) dated 1/18/11, which indicated resident #1 had long and short-term memory deficits with severely impaired cognitive skills for daily decision making. The MDS indicated resident #1 had physical behavior symptoms directed towards others, which occurred 4-6 days, but less than daily. The MDS indicated resident #1's behaviors put others at significant risk for injury. The MDS indicated resident #1 required supervision with locomotion on the unit. The facility completed a CAA (Care Area Assessment) for resident #1's behaviors (without date when completed). The CAA indicated resident #1 had severe dementia and needed close supervision, as the resident would wander into other rooms and inappropriately touch others. Resident #1's nurses' notes indicated the following: On 1/6/11 the resident was extremely confused, wandering on the unit all shift and shaking other resident's chairs. No violence was noted. On 1/7/11 at 11:43 a.m. resident #1 was in the lounge. While trying to go past another resident, resident #1 put his hand on the other resident's head and began putting his weight on the other resident's head to get around her. The other resident began to yell, and the CNA (Certified Nursing Assistant) intercepted and redirected resident #1. On 1/7/11 at 8:18 p.m. resident #1 was documented as wandering without purpose all shift and having multiple contacts with other residents. No violent intentions were noted. Other residents and family of residents voiced concerns of being frightened by resident #1 being too close and touching them. Redirection was documented as effective but short acting. On 1/27/11 at 10:15 a.m. surveyor # interviewed RN (Registered Nurse)-I regarding resident #1. RN-I verified he documented in resident #1's nurses' notes on 1/6/11 and 1/7/11 at 8:18 p.m. RN-I stated on 1/6/11 resident #1 was wandering throughout the lounge. Other residents were present, and resident #1 would grab the back of residents' chairs and would shake the chairs. RN-I indicated staff would intervene, but resident #1 would continue to shake the back of residents' chairs. RN-I stated on 1/7/11 resident #1 was wandering in the lounge and continued to shake residents chairs and get into other residents' personal space. Other residents expressed they were upset and were heard saying, "Get your hands off of me" and "Get your hands off of my chair." RN-I stated he was not actually sure if resident #1 touched other residents. RN-I indicated a resident's family voiced concerns about resident #1. RN-I indicated other residents indicated they were afraid resident #1 might "do something". RN-I indicated staff discussed resident #1 daily, and it was decided to keep resident #1 under close supervision. RN-I stated resident #1 was not on 1:1 monitoring, but staff would check for his whereabouts every few minutes. RN-I indicated resident #1 was independently ambulatory on the unit and was confused. RN-I indicated resident #1 touched everything around him, and his behaviors were unpredictable. RN-I stated resident #1 was difficult to supervise during supper hour, as staff were busy working with other residents. On 1/27/11 at 1:00 p.m. surveyor # interviewed RN-K regarding documentation on 1/7/11 at 11:43 a.m. RN-K stated one of the CNAs told her resident #8 was sitting in her chair in the lounge (resident #8 could not move), and resident #1 placed his hand on resident #8's head and pushed downward to get around the chair. RN-K indicated resident #8 yelled sounds. RN-K stated she thought the CNA had to physically remove resident #1's hands from resident #8. RN-K indicated she updated the DON (Director of Nursing) of the incident but could not recall what was told to her. Nurses' notes for resident #1 continued on as follow: On 1/8/11 resident #1 was wandering throughout the shift from one hall way to the other, entering resident rooms and knocking things over. The writer observed resident #1 a couple of times holding and pressing another resident's chest. Resident #1 was reminded not to hit or hold residents. Staff did their best with 1:1 but there wasn't much improvement. On 1/9/11 documentation indicated resident #1 moved with no purpose, wandered through the nursing home and wandered into other residents' rooms. Documentation indicated resident #1 was holding some residents and climbing chairs. The notes indicated staff was mostly 1:1, and resident #1 was redirected and monitored. On 1/31/11 at 9:10 a.m. surveyor # interviewed RN-P regarding resident #1. RN-P verified he completed documentation for 1/8/11 and 1/9/11. RN-P stated on 1/8/11 resident #1 was in the lounge with resident #6. RN-P stated resident #1 grabbed resident #6's shirt, and made a fist and then pushed his fist into resident #6's chest. RN-P indicated resident #6 did not respond to resident #1's actions. RN-P stated he needed to physically remove resident #1's hands from resident #6. RN-P stated another resident's family member reported to staff resident #1 grabbed another resident's hand and was pushing on her. RN-P stated he could not recall specific resident names. RN-P indicated he told staff to monitor resident #1 closely in an attempt to keep other residents safe, but resident #1 was not placed on 1:1 supervision. Resident #1's nurses' notes went on to indicate: On 1/11/11 a late entry for 1/10/11 indicated resident #5 was sitting in her chair in the lounge, and resident #1 was observed standing next to resident #5 holding onto both of her wrists. Resident #5 said, "Oh grandma, oh grandma." On 1/27/11 at 9:30 a.m. surveyor # interviewed RN-D regarding resident #1. RN-D indicated resident #1 was independently ambulatory on the unit, was in/out of other resident rooms and required close observation. RN-D stated resident #1 had been watched closely by staff since admission, but close observation was very difficult. RN-D indicated watching closely meant staff trying to observe resident #1 from a distance and redirected when needed. RN-D stated when resident #1 was redirected it was effective for only a couple of minutes. RN-D verified she had written documentation for resident #1 for the 1/10/11 late entry. RN-D stated she came around the corner and observed resident #1 holding resident #5's wrists tightly. Resident #1 was twisting his hands around resident #5's wrists like a "snakebite". RN-D indicated staff had to pry resident #1's fingers off from resident #5. RN-D indicated she didn't know what precipitated the event of 1/10/11, as resident #5 just sat in her chair. RN-D indicated resident #5 did not verbally express much, other than "oh grandma" repeatedly, even when she experienced pain. RN-D indicated she had touched resident #5's wrists later, and the resident stated, "Oh grandma." RN-D stated she wasn't sure if resident #5 was in pain, but she administered Tylenol. RN-D stated the altercation with resident #5 was resident #1's first altercation with other residents. RN-D stated she didn't know if the event was considered abuse, but she told the nurse supervisor of the incident. RN-D stated the nurse supervisor told her to complete an incident report. RN-D indicated after the incident of 1/10/11, the ADON (Assistant Director of Nursing) developed a temporary care plan, which directed staff to keep resident #1 in line of vision. RN-D verified the intervention to keep in line of vision was already being done by staff. RN-D indicated resident #1 was placed on 1:1 monitoring after the 1/10/11 incident, but the 1:1 supervision was only completed for the next four to six hours. RN-D indicated she was not sure who decided to discontinue the 1:1 monitoring. RN-D stated she expressed her concern to management staff about resident #1 not being on 1:1 monitoring and was told the facility was low census; other resources could be used, such as activities and therapies; and to do the best they could. RN-D indicated close supervision was not effective. RN-D indicated technically there was not a change to resident #1's plan of care, but it was just written on the plan of care to watch closely. RN-D verified the intervention to watch closely was not always possible. Resident #1's nurses' notes continue: On 1/13/11 resident #1 was documented as confused the am shift, wandering up and down the hallways and into and out of other residents' rooms. Resident #1 was laying on other residents' beds during the am shift and needed to be redirected several times. Resident #1 was documented as picking at other residents' heads and shirts. On 1/14/11 resident #1 patted another resident's head and was redirected. Resident #1 grabbed and raised another resident's legs and was redirected. Resident #1 was on 1:1 supervision for three hours. On 1/15/11 resident #1 was in the lounge and grabbed the crotch of resident #7's pants, requiring intervention of staff. Resident #1 was redirected with two assist. The incident was reported to the nursing supervisor. On 1/27/11 at 1:00 p.m. surveyor # interviewed RN-K regarding documentation of 1/15/11. RN-K verified she had completed the documentation. RN-K stated, "I think someone reported to me that (resident #1) grabbed the crotch of (resident #7's) pants. (Resident #7) was alert but confused, but I thought (resident #1) was only pulling on his pants." Nurses' notes continue: On 1/17/11 resident #1 hit resident #9 on the head three times with a closed fist. The altercation was witnessed by COTA (Certified Occupational Therapy Assistant)-Q. Resident #1 was ambulating in the lounge. Documentation indicted staff would continue close watch and monitoring; 1:1 supervision. The physician was updated, and medications were changed. During the 1/27/11 at 9:30 a.m. interview with surveyor # RN-D indicated COTA-Q came to her and said there was a resident in the lounge that just got struck by another resident. RN-D indicated she was told resident #9 was just sitting in the lounge when resident #1 walked up to her and hit her in the head with a closed fist. RN-D indicated COTA-Q said the strike was hard and intentional. RN-D stated resident #9 was crying after the incident. RN-D indicated resident #9 had a small amount of redness on the side of her head where resident #1 had struck her. RN-D stated she updated resident #9's POAHC (Power of Attorney for Health Care). The POAHC was very upset and demanded 1:1 supervision for resident #1. RN-D verified resident #1 was not on 1:1 supervision prior to the incident. RN-D stated resident #1 was placed on 1:1 supervision for the remainder of the shift, but the 1:1 supervision was discontinued when the shift was over. RN-D indicated resident #1 was a threat to other residents when he was not on 1:1 supervision. RN-D verified other residents were afraid of resident #1. RN-D stated resident #1 was currently on 1:1 supervision on days/pms. On 1/31/11 at 9:30 a.m. surveyor # interviewed COTA-Q regarding her observation of 1/17/11. COTA-Q stated by the time she observed resident #1, the resident was already in the process of hitting resident #9. COTA-Q indicated she observed resident #1 strike resident #9 with a closed fist on the right side of the head. COTA-Q stated she observed resident #1 deliver three strikes to resident #9's head. COTA-Q indicated resident #9 was yelling, "Ow, he's hitting me!" COTA-Q stated resident #9 was observed to have her hand up in an attempt to block resident #1's strikes. COTA-Q indicated she yelled for help and pulled resident #9's wheel chair away from the situation. Resident #1 just walked away. COTA-Q indicated she had never observed resident #1 strike other residents prior to 1/17/11. COTA-Q verified resident #1 wandered the unit independently, and staff attempted to supervise. COTA-Q indicated she was aware there were other residents who expressed concerns for their safety related to resident #1. Nurses' notes continued: On 1/18/11 resident #1 was on 1:1 supervision all shift. The problem of safety risk for self and others was added to the care plan. Approaches were utilizing 1:1 assist at 4 hour intervals. All nursing staff and other department staff observe him when on the unit for safety issues. To utilize a sensor alarm for resident #8, and the yellow Velcro tape... A plan of care was developed on 1/18/11 for resident #1 for "Safety Risk for Self and Others." The plan of care directed the following: - All staff from nursing and other departments to watch him for safety issues - Utilize a sensor alarm on over bed table near resident #8 - Keep yellow Velcro across room (resident #8's room) doorway - Engage him as able by walking and talking with him. Offer soft objects, blankets, sheepskin and pillows. Offer him finger food while walking to improve his appetite as well as provide him with something to do - If he stops at desk give him paper/color to draw on; something to drink - Seen by by Nurse Practitioner-started on Seroquel (antipsychotic)-monitor effects - Offer Lorazepam (antianxiety) as needed for restlessness and undirectable activity. The nurses' notes continued as follows: On 1/20/11 the Nurse Practitioner was at the facility to see resident #1. Medications were changed..... On 1/22/11 resident #1 moved with no purpose, was easily directed twenty times and wandered into other residents' rooms, was pulling off yellow door blocks and ducking underneath yellow door blocks. On 1/23/11 resident #1 was in the lobby, walked up to another resident who was in a wheel chair and grabbed onto her pant leg. Staff required assistance to get resident #1 to let go of the other resident's pant leg. Resident #1 was easily redirected after he let go of the pant leg. On 1/24/11 resident #1 hit another resident, per resident #7's statement. Resident #7 said to CNA-O that resident #1 entered resident #7's room, was standing by resident #7 while he was asleep and hit resident #7 on the chest. Resident #7 said it frightened him. 1:1 was immediately put on with a staff member. The Nurse Practitioner was updated, and orders were received for medication changes. On 1/31/11 at 8:45 a.m. surveyor # interviewed CNA-O regarding the incident of 1/24/11. CNA-O indicated he had not seen resident #1 for a few minutes, so he thought he should go check where the resident was. CNA-O stated he went to check the whereabouts of resident #1, as the resident had a history of [REDACTED]. CNA-O stated he found resident #1 in resident #7's room, standing at the end of the bed. CNA-O indicated resident #7 was demonstrating that he was struck in the chest with a closed fist and later said, "He hit me." CNA-O stated resident #7 said he was frightened of resident #1. CNA-O indicated resident #1 only had 1:1 supervision for a short time after the incident on 1/17/11, when he struck resident #9 on the head. CNA-O indicated he was not sure why the 1:1 supervision was discontinued for resident #1. CNA-O stated nurses said to keep resident #1 in sight, but it was not always possible to watch the resident. CNA-O indicated after resident #1 had the altercation with resident #7 on 1/24/11, he was placed on 1:1 supervision; however, CNA-O was unsure if the 1:1 supervision was discontinued. Nurses' notes continued: On 1/25/11 at approximately 7:00 a.m. resident #1 went into resident #2's room while the resident was sleeping and began pulling on resident #2's blankets. Resident #2 yelled, and a CNA responded and redirected resident #1 without problem. On 1/25/11 at 8:12 a.m. resident #1 hit another resident on the face twice with a closed fist and was pulling on the other resident's shirt. Resident #1 was difficult to redirect from the situation. 1:1 supervision was initiated following the incident. The facility updated resident #1's plan of care for "Safety Risk for Self and Others" on 1/25/11. Interventions were as follows: - 1:1 staffing for resident during waking hours - Sensor alarm on resident's doorway to alert unit staff that he is awake and out of room - Lock bathroom door of resident that he shares bathroom with - Get into his reality, if he wants to walk- walk. Try not to force him to do anything he does not want to do - If resident is so tired he is almost falling down or needs to use the bathroom, in a calm manner guide him with both hands to recliner chair, wheel chair, toilet or bed. Recruit a second staff person to help - Avoid the areas where other residents gather, as the lounge. Utilize quiet areas, former kitchen, his room, walk hallway 1:1 - Assure proper nutrition.... - Offer treats----- - Continue use of yellow Velcro strips across other residents' doorways on unit - Scheduled medications... - If resident does hit another resident, proceed with current plan to contact Police Department. On 1/27/11 at 1:00 p.m. surveyor # interviewed RN-K regarding documentation for 1/24/11 and 1/25/11. RN-K stated on 1/24/11 CNA-O reported to her that resident #7 reported to him resident #1 hit him in the chest and he was frightened. RN-K stated resident #1 was placed on 1:1 monitoring for the remainder of the shift. RN-K indicated 1:1 monitoring was discontinued after the shift, and the RN did not know why the 1:1 monitoring was discontinued. RN-K indicated she thought other residents' safety was at risk when resident #1 was not on 1:1 supervision. RN-K stated on 1/25/11 at 7:00 a.m. resident #2 was yelling. A CNA responded and observed resident #1 pulling on resident #2's blankets. RN-K indicated then, at approximately 7:30 a.m., she was in the medication room and could observe into the lounge area; when she observed resident #1's fists flying and observed resident #11 holding onto resident #1's fists to push them away. RN-K indicated resident #11 said that resident #1 struck him twice on the face and either on the chest or his shoulder. RN-K stated resident #11 was not injured. RN-K indicated resident #11 had periods of confusion but was alert. RN-K indicated she assessed resident #11 and observed a small darker area on his left cheek, but she was unsure if it was caused by the strikes or was already there. RN-K indicated when she had touched the area, resident #11 complained of tenderness. RN-K verified resident #1 was placed on 1:1 monitoring when awake on 1/25/11. On 1/27/11 at 12:15 p.m. surveyor # interviewed ADON-G regarding resident #1 and the facility's interventions to keep other residents safe from resident #1. ADON-G stated initially resident #1 was not a threat to other residents. ADON-G indicated resident #1's first altercation was with resident #5 on 1/17/11 when he grabbed her wrists. ADON-G indicated she was not aware of any concerns from residents or residents' families regarding their safety from resident #1. ADON-G stated resident #1 was confused but ambulated independently throughout the unit. ADON-G stated resident #1 entered other resident rooms a few times, and that was when the facility placed yellow strips across resident doorways. ADON-G indicated once in awhile resident #1 would remove the strips but she was unsure if resident #1 ever entered resident rooms after he had removed the yellow strips. ADON-G stated after the incident with resident #5 on 1/17/11, a plan of care was developed. ADON-G indicated resident #1 was placed on fifteen minutes checks on 1/6/11 at 1:00 p.m., due to concerns for wandering. Surveyor # reviewed nurses' notes for resident #1 with ADON-G. ADON-G stated she was aware staff implemented 1:1 supervision for resident #1 for short periods of time. ADON-G verified she was not aware of the entry on 1/7/11 where residents and families had expressed concern for their safety. ADON-G stated she was unsure why resident #1 was placed on 1:1 supervision for a time on 1/8/11. ADON-G stated 1:1 supervision was discontinued on 1/10/11, as the facility staff felt the change in medications was sufficient for resident #1's behaviors; and resident #1 was being watched closely. ADON-G verified 1:1 supervision was not initiated after the incident on 1/17/11, as the nurse practitioner changed resident #1's medications. ADON-G indicated resident #1 was placed on 1:1 supervision on 1/18/11 for the pm shift; but after the shift, the 1:1 supervision was discontinued. ADON-G indicated the 1:1 supervision was discontinued because staff thought 1:1 supervision was no longer needed. ADON-G indicated 1:1 supervision was started again on 1/24/11 but was also discontinued later that day. ADON-G was not sure specifically when the 1:1's were discontinued. ADON-G indicated she really thought incidents with resident #1 were random and medication changes would help. ADON-G verified 1:1 supervision for resident #1 when the resident was awake was started on 1/25/11. On 1/27/11 at 12:25 p.m. surveyor # interviewed resident #9. Resident #9 stated she was hit by a man, but didn't know his name. Resident #9 indicated the man "...just walked up to me and hit me in my bad arm." Resident #9 stated she always had her fists closed when the man came around, indicating, "It will take two people to get him up after I'm through with him. He's vicious." On 1/27/11 at 2:00 p.m. surveyor # interviewed RN-J regarding the night shift. RN-J verified she implemented 1:1 supervision for resident #1 on the night shift on 1/8/11 only until the resident fell asleep. RN-J stated resident #1 woke up around 4:30 a.m. to 5:00 a.m. every day, got dressed and was taken to the lounge. RN-J indicated recently, on either 1/25/11 or 1/26/11, a motion sensor was placed on the resident's door, so staff were aware when he left his room. RN-J stated night shift was not expected to do anything different with resident #1. RN-J indicated resident #1 was in direct supervision of the night shift if he awoke. RN-J stated sometimes other residents were in the lounge area while resident #1 was in the lounge. RN-J indicated she observed resident #1 interact with other residents in the lounge. Resident #1 usually taped on the top of other residents' chairs, and she redirected him. RN-J indicated she heard in nurses' report resident #1 struck other residents, and she was unaware if resident #1's behavior was predictable or not. RN-J stated she questioned why resident #1 had a sensor alarm on his door, and she was told it was to notify staff when resident #1 left his room. RN-J stated resident #1 was not on 1:1 supervision on the night shift when he was awake and would leave his room. RN-J indicated she would keep him in direct supervision, indicating, "...my choice." RN-J stated if resident #1 needed 1:1 supervision on the night shift while he was awake, she would need more staff. On 1/27/11 at 3:00 p.m. surveyor # interviewed CNA- L and CNA-M regarding resident #1. CNA-L and CNA-M stated resident #1 independently ambulated in and out of resident rooms since admission to the facility. The CNAs stated even when the facility placed yellow door strips across resident doors in attempt to keep resident #1 out, he would still go right through the strips and into the rooms. CNA-L and CNA-M stated resident #1 was not verbal, but indicated they believed resident #1 knew, at times, what he was doing because; when they would say things to him, he would look at them and smirk. CNA-M stated there was a incident when she observed resident #1 with both of his hands around resident #5's throat. CNA-M stated staff needed to release resident #1's hands. CNA-M indicated she thought the incident was the first incident resident #1 had with another resident, and the incident occurred around the third day of admit. CNA-M stated the nurse was aware, as she was at the nurses' station, but could not recall who the nurse was. CNA-M verified there were no changes to supervise resident #1 after the incident. CNA-M indicated resident #1 was on fifteen minutes checks since admission, but that was due to wandering. CNA-L and CNA-M verified resident #1 was on isolated 1:1 supervision, but only for short periods of time. CNA-L and CNA-M indicated they did not know why 1:1 supervision was discontinued. CNA-L and CNA-M indicated staff would always try to have resident #1 in line of sight, but that was not always possible. CNA-L and CNA-M stated when resident #1 struck out he was totally unpredictable and could hurt someone. CNA-L and CNA-M stated it was possible for resident #1 to enter another resident room undetected by staff and without staff ever knowing it had occurred. CNA-M and CNA-L stated other residents had expressed fear of resident #1. On 1/31/11 at 10:15 a.m. surveyor # interviewed DON-A regarding a behavior assessment for resident #1. DON-A verified the facility did not complete a behavior assessment for residents in an attempt to identify causal factors for behaviors. On 1/31/11 at 12:10 p.m. surveyor # interviewed resident #12. Resident #12 stated, "I am afraid of that man." Resident #12 indicated she wasn't sure of the man's name, but he walked around the facility; and now staff were with him. Resident #12 stated, "He has scary eyes", and he walks around and touches everything. Resident #12 indicated she was unsure of what the man was going to do. On 1/31/11 at 12:35 p.m. surveyors # and # interviewed ADON-G regarding resident #1. ADON-G verified she was not aware of any re-education done with nursing staff or changes in the policy and procedure to ensure staff knowledge of how to handle resident-to-resident altercations. ADON-G verified resident #1 was placed on short term, intermittent 1:1 supervision, but could not verify when each 1:1 was discontinued. ADON-G stated the intermittent 1:1 supervision was discontinued because of medication changes, and resident #1 became calm. ADON-G verified a plan of care for resident #1's altercations with other residents was not developed until 1/18/11.